What are the responsibilities and job description for the Grievance Resolution Specialist position at SUNSHINE ENTERPRISE USA LLC?
Company Overview : Our client is a leading healthcare located in Orange CA seeking a Grievance Resolution Specialist who will be responsible for coordinating the grievance and appeal resolution process. The incumbent will respond to verbal and written grievances and appeals from members and providers relating to member eligibility and benefits contract administration claims processing utilization management decisions and pharmacy and vision decisions.
Position Summary : The ideal candidate shall hold the associate s degree in business health care administration or related field and has at least 1 year of experience in any of the following areas : Grievances and Appeals Claims Regulatory Compliance Customer Service or related field required.
Work Duration : Monday Friday 40 hours / week.
Work Duration : Up to 6 months (Contract)
Job Type : Onsite (Full office)
Department : Grievance & Appeals
Position Responsibilities :
Gathers pertinent information regarding the grievances and appeals received including member or provider concerns supporting information related to initial decisionmaking 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.
Assists the team in carrying out department responsibilities and collaborates with others to support short and longterm 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.
Assists the team in carrying out department responsibilities and collaborates with others to support short and longterm 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
Requirements
Experience & Education :
Associate s degree in business health care administration or related field.
1 year of experience in any of the following areas : Grievances and Appeals Claims Regulatory Compliance Customer Service or related field required.
Experience in health care practice standards for both government and commercial plans.
Bilingual in English and one of the following languages : Arabic Farsi Chinese Korean Spanish or Vietnamese
Necessary Attributes :
Develop rapport and establish and maintain effective working relationships with leadership and staff and external contacts at all levels and with diverse backgrounds
Work independently and exercise sound judgment.
Communicate clearly and concisely both orally and in writing.
Work a flexible schedule; available to participate in evening and weekend events
Organize be analytical problemsolve and possess project management skills
Work in a fastpaced environment and in an efficient manner.
Manage multiple projects and identify opportunities for internal and external collaboration.
Motivate and lead multiprogram teams and external committees / coalitions.
Utilize computers and appropriate software (e.g. Microsoft Office : Word Outlook Excel PowerPoint) and job specific applications / systems
Benefits
Benefits :Schedule :
- 8 hour shift
- Day shift
- Monday to Friday
Criteria : - BSN / Diploma in Nursing -At least 2 years Experience - Medical License
Education
Criteria : - BSN / Diploma in Nursing -At least 2 years Experience - Medical License
