Company Overview: Sunshine Enterprise is an industry-leading Staffing and Recruitment Firm. Our clients are Fortune 500 companies, high-growth start-up companies, government, and private equity firms, and lead professional services firms. As a leading force in the business landscape, we take pride in bringing together great people and great organizations by fostering a work environment that values creativity, diversity, and growth. If you're ready to embark on a rewarding career journey with a company that prioritizes its employees, explore our current job opportunities below.

Job Summary

Under general supervision, the Program Assistant will assist with specialized services relevant to the Grievance and Appeals Resolution Services (GARS) department. The incumbent will work independently, exercising discretion and judgment and may assist in coordinating a function for the program assigned. The incumbent’s primary responsibilities will include monitoring the GARS member and provider mailbox, fax, mail and processing appeals and grievances for assignment to key staff within the required timeframe.

Position 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.
• Serves as point of contact within or outside of the company for inquiries related to grievances and appeals.
• Monitors incoming complaints via the Customer Service system routing, interdepartmental referral, mail, telephone, fax or via email from the website for members and providers.
• Monitors for inquiry requests from the Department of Managed Health Care (DMHC), Medicare Complaint Tracking Module (CTM) from the Centers for Medicare Medicaid Services (CMS), the Medicare Quality Improvement Organization (QIO) and the State Hearing Office from Department of Social Services (DSS).
• Responds to DMHC requests for information on a timely manner.
• Works with internal and external departments and providers in gathering supporting information relevant to the case.
• Sets up complaint case files, enters cases in the GARS system with accurate classification and category types and assigns to appropriate staff.
• Generates acknowledgment letters for all lines of business per department and regulatory standards.
• Assists in the development of departmental forms and intake process.
• Coordinates administrative support for state hearings including serving as contact with DSS for incoming cases, entering cases in the GARS system, creating electronic file and routing the scanned documents to designated staff and faxing required state hearing documentation to local hearing office as necessary.
• Completes other projects and duties as assigned.

Possesses the Ability To:

• Provide professional support to supervisors and staff in program to which assigned.
• Coordinate multiple administrative activities.
• Work on specialized process or function to which assigned.
• Establish and maintain effective working relationships with leadership and staff.
• Communicate clearly and concisely, both orally and in writing.
• Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment

Experience & Education

• High School diploma required.
• 1 year of experience in appeal and grievance guidelines or Medi-Cal/Medicaid or Medicare programs required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.

Preferred Qualifications

• Bilingual in English and in one of the following languages: Arabic, Chinese, Farsi, Korean, Spanish, and Vietnamese, preferred.

Knowledge of:

• Services, policies and general responsibilities of program to which assigned.
• Practices and techniques required to function with professions working in assigned program.
• Methods and techniques for organizing and implementing processes.
• General information relevant to professional or administrative responsibilities in assigned program.

At Sunshine Enterprise USA LLC, we firmly believe that our employees are the heartbeat of our organization, and we are happy to offer the following benefits:

• Competitive pay & weekly paychecks
• Health, dental, vision, and life insurance
• 401(k) savings plan
• Awards and recognition programs
• Benefit eligibility is dependent on employment status.

SUNSHINE ENTERPRISE USA LLC is an Equal Opportunity Employer and does not discriminate on the basis of race or ethnicity, religion, sex, national origin, age, veteran disability or genetic information or any other reason prohibited by law in employment.