Job Description
Job Description
Grievance and Appeals Coordinator
CalOptima
$28-31/HR
Orange CA - 92868
Duties & Responsibilities: 95% - Program Support 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 CalOptima Health’s 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.
5% - Completes other projects and duties as assigned.
Minimum Qualifications: High school diploma or equivalent PLUS 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; 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. 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.
Preferred Qualifications: Associate 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).
Required Licensure / Certifications: N/A Knowledge & Abilities: Develop rapport and establish and maintain effective working relationships with CalOptima Health's 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, problem-solve and possess project management skills. Work in a fast-paced environment and in an efficient manner. Manage multiple projects and identify opportunities for internal and external collaboration. Motivate and lead multi-program teams and external committees/coalitions. Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Company DescriptionIT Mantra, LLC. is a Certified Woman / Minority (WBE/MBE) owned company founded in 2003 and based in Massachusetts. We provide a comprehensive range of IT and Professional Staffing and Workforce Solutions that include contract, contract to hire and direct hire placement services as well Employer of Record (EOR) services nationally and specialize in the placement of women and diverse personnel.
Company Description
IT Mantra, LLC. is a Certified Woman / Minority (WBE/MBE) owned company founded in 2003 and based in Massachusetts. We provide a comprehensive range of IT and Professional Staffing and Workforce Solutions that include contract, contract to hire and direct hire placement services as well Employer of Record (EOR) services nationally and specialize in the placement of women and diverse personnel.