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NEOGOV · 12 hours ago

Grievance Resolution Specialist

Orange, CA

Full-time

Hybrid

Entry Level

$54K/yr - $81K/yr

1+ years exp

CalOptima is a mission-driven community-based organization focused on serving member health with excellence and dignity. The Grievance Resolution Specialist will coordinate the grievance and appeal resolution process, responding to grievances and appeals from members and providers while collaborating with various internal departments to ensure optimal resolution.

GovTechHuman ResourcesInformation TechnologySoftware

Responsibilities

Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability

Maintains adequate information in CalOptima Health's systems; ensures data collection, summarization, integration and reporting, including case creation and management and events/activity tracking

Gathers pertinent information regarding the grievances and appeals received, including member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal, or supplemental information required to evaluate grievances and appeals within regulatory requirements

Coordinates and participates in case discussions with operational experts to result in a final case disposition as needed

Evaluates case details, proposes recommendations, or makes decisions as applicable, ensures the organization's decision is implemented according to the Grievance and Appeals policies and case resolution

Develops resolution letters and correspondence to members and providers

Communicates with internal and external customers to ensure timely review and resolution of grievances or appeals

Initiates referrals to the Quality Improvement department as applicable and facilitates responses to members according to CalOptima Health policy

Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department

Assists with health networks' compliance process

Meets performance measurement goals for Grievance and Appeals Resolution Services (GARS)

Identifies trends and root cause of issues, proposes solutions, or escalates ongoing issues to management

Completes other projects and duties as assigned

Qualification

Grievance resolution experienceRegulatory compliance knowledgeCustomer service skillsHealth care administrationBilingual (English + language)Analytical skillsProject management skillsCommunication skillsProblem-solving skillsCollaboration skills

Required

High school diploma or equivalent PLUS 1 year of experience in grievances and appeals, claims, regulatory compliance, customer service or related field required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying