What are the responsibilities and job description for the Grievance Resolution Specialist position at TotalMed?
Position Title – Grievance Resolution Specialist (Health Insurance)
Location- Orange, CA 92868
Pay – $30/hr
Start date – ASAP
Hours – Monday to Friday (8:00 a.m. to 5:00 p.m.)
Contract Type – 6 month contract
Required Skills & Education:
- High school diploma or equivalent
- 1 year of experience with Provider Dispute Resolution (PDR) in Medicare and Medi-Cal in professional, institutional, outpatient, ancillary, coordination of benefits and government cases required
- 1 year of experience with Medicare or Medi-Cal provider appeals and denials process required.
- 1 year of experience in any of the following areas: Grievances and Appeals, Claims Administration, Regulatory Compliance, Customer Service or related field required
- Associate degree in business, health care administration or related field preferred
- Experience in health care practice standards, for both government and commercial plans preferred
- Bilingual in English and in Arabic, Farsi, Chinese, Korean, Spanish, or Vietnamese preferred
Responsibilities:
- Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
- Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
- Maintains adequate information in the systems; ensures data collection, summarization, integration and reporting which includes 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 and 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.
- Contacts appropriate parties to request and obtain missing information and supporting documentation or provides education.
- Reads and interprets provider contracts, Division of Financial Responsibility (DOFR), policies, procedures and instructions.
- Responds to routine provider inquiries via phone, assisting with provider appeals resolution inquiries.
- Assists with the health networks’ compliance process.
- Identifies trends and root causes of issues, proposes solutions or escalates ongoing issues to management.
- Meets performance measurement goals for Grievance and Appeals Resolution Services.
- Completes other projects and duties as assigned.
#INDJB
Job Types: Full-time, Contract
Pay: $30.00 per hour
Benefits:
- Dental insurance
- Health insurance
- Vision insurance
Schedule:
- 8 hour shift
- Day shift
- Monday to Friday
Education:
- High school or equivalent (Preferred)
Ability to Commute:
- Orange, CA 92868 (Required)
Work Location: In person
Salary : $30
