Resolution specialist

Direct Client : CalOptima Health

Job Title : Grievance Resolution Specialist

Duration : 06 Months

Start Date : ASAP

Location : 505 City Parkway West, Orange, 92868 CA (Onsite)

Position Type : Contract

Interview Type : Web Interview

Ceipal ID : CAL HD408 IK

Job ID : 408

Job Summary

• CalOptima Health is seeking a highly motivated and experienced TEMP - Grievance Resolution Specialist to join our team.
• The Grievance Resolution Specialist will be responsible for coordinating the grievance and appeal resolution process.
• The candidate 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.
• The candidate will have frequent external contact with members and families, health care providers, health networks, third party administrators, and regulators.
• The candidate will collaborate with internal departments such as Customer Service, Provider Relations, Pharmacy, and Medical Management to identify factors necessary for the optimal resolution of Grievances and Appeals.

Duties & Responsibilities :

80% - Program Support

• 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.

15% - Administrative Support

• 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.

Minimum Qualifications :

• High School diploma or equivalent required.
• 1 year of experience in any of the following areas : 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

Preferred Qualifications :

• Associate's degree in business, health care administration, or related field.
• Experience in health care practice standards for both government and commercial plans.
• Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese)

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Last updated : 2024-11-23