What are the responsibilities and job description for the Grievance and Appeals Specialist position at Robert Half?
A Medical IPA Company in Mid-Wilshire is seeking a dedicated and detail-oriented Grievance and Appeals Specialist to join our team. The ideal candidate will play a crucial role in ensuring our members receive excellent service and fair resolution of grievances and appeals in compliance with regulatory guidelines. This position requires strong analytical skills, superior communication abilities, and a customer-focused mindset to deliver timely and accurate support to our members and healthcare providers.Key Responsibilities:Manage and resolve member grievances and appeals with sensitivity and professionalism in accordance with company policies and state/federal regulations.Conduct thorough investigations, reviews, and evaluations of all grievances and appeals, ensuring accurate and timely documentation in applicable systems.Communicate decisions clearly and effectively to members, providers, agencies, and other stakeholders while maintaining confidentiality and compliance standards.Monitor and track all grievances and appeals to meet deadlines and regulatory requirements, ensuring adherence to all required timeframes.Collaborate with clinical and administrative teams to gather necessary information and ensure proper resolution of complex cases.Provide educational support and guidance to members and staff regarding grievance and appeal processes.Stay updated on relevant state and federal policies, regulations, and industry trends impacting grievance and appeal procedures.Assist in identifying process improvement opportunities to enhance member satisfaction and organizational efficiency.
Salary : $23 - $30
