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Member Liaison Specialist (Customer Service) CalOptima Join Us in this Amazing Opportunity The Team You'll Join We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all. More About the Opportunity We are hoping you will join us as a Member Liaison Specialist (Customer Service) and help shape the future of healthcare where you'll be an integral part of our CS - Member Liaison team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. You will provide member service to seniors, persons with disabilities or chronic conditions, persons without housing and persons under the age of twenty-one (21) who participate in the Whole-Child Model program. You will also serve as a liaison between members, health networks, providers and community-based organizations to facilitate access to services and help resolve health care and psychosocial issues. Together, we are building a stronger, more equitable health system. Your Contributions To the Team: 
<ul>
<li>85% - Member Support
<ul>
<li>Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.</li>
<li>Assesses members' concerns to identify psychosocial or health care issues and facilitate an appropriate resolution.</li>
<li>Intakes information from members, both over the phone and/or in person, to complete requests for assistance cases, grievances and appeals, per departmental guidelines.</li>
<li>Coordinates members' health care and social service needs within and outside the health network and CalOptima Health during the original interaction.</li>
<li>Addresses member and provider inquiries, questions and concerns in all areas, including enrollment, claims, benefit interpretation, coordination of care and referrals/authorizations for medical care related to services covered under the Whole-Child Model program.</li>
<li>Guides members in understanding and accessing the benefits under the Whole-Child Model program.</li>
<li>Maintains documentation of member cases within the FACETS system.</li>
<li>Initiates referrals to internal and external care management departments and government agencies.</li>
<li>Communicates with community-based organizations, health networks, providers and vendors on behalf of members to resolve disputes, helps coordinate access to care and investigates issues preventing members from receiving medical benefits and services. </li>
</ul>
</li>
<li>10% - Administrative Support
<ul>
<li>Collaborates with interdepartmental staff in call resolution as needed.</li>
<li>Identifies calls needing case management or escalation to a supervisor, manager or director and routes them according to established guidelines.</li>
<li>Meets all regulatory key performance indicators, first call resolution requirements and business objectives of CalOptima Health. </li>
</ul>
</li>
<li>5% - Other
<ul>
<li>Completes other projects and duties as assigned. </li>
</ul>
</li>
</ul>
 Do You Have What the Role Requires? 
<ul>
<li>High school diploma or equivalent PLUS 2 years of experience as a call center agent or customer/member services representative in health care 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.</li>
</ul>
 You'll Stand Out More If You Possess the Following: 
<ul>
<li>2 years of experience working with the needs of persons with disabilities and chronic medical conditions in a customer/member service capacity. </li>
<li>Health maintenance organization (HMO), Medi-Cal/Medicaid and health services experience. </li>
<li>Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese).</li>
</ul>
 What the Regulatory Agencies Need You to Possess? 
<ul>
<li>N/A</li>
</ul>
 Your Knowledge &amp; Abilities to Bring to this Role: 
<ul>
<li>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. </li>
<li>Work independently and exercise sound judgment.</li>
<li>Communicate clearly and concisely, both orally and in writing.</li>
<li>Work a flexible schedule; available to participate in evening and weekend events.</li>
<li>Organize, be analytical, problem-solve and possess project management skills.</li>
<li>Work in a fast-paced environment and in an efficient manner.</li>
<li>Manage multiple projects and identify opportunities for internal and external collaboration.</li>
<li>Motivate and lead multi-program teams and external committees/coalitions.</li>
<li>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.</li>
</ul>
 Your Physical Requirements (With or Without Accommodations): 
<ul>
<li>Ability to visually read information from computer screens, forms and other printed materials and information.</li>
<li>Ability to speak (enunciate) clearly in conversation and general communication.</li>
<li>Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.</li>
<li>Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.</li>
<li>Lifting and moving objects, patients and/or equipment 10 to 25 pounds</li>
</ul>
 Ways We Are Here For You 
<ul>
<li>You'll enjoy competitive compensation for this role.
<ul>
<li>Our current hiring range is: Pay Grade: 302 - $49,754 - $69,655 ($23.92 - $33.4880). 
<ul>
<li>The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors. </li>
</ul>
</li>
</ul>
</li>
<li>This position is approved for Full Office (**If the position is Telework, it is eligible in California only**) </li>
<li>A <a href="https://apptrkr.com/get_redirect.php?id=6757493&amp;targetURL=https://www.caloptima.org/en/careers#benefits" target="_blank">comprehensive benefits package</a> </li>
<li>CalPERS pension program and additional retirement packages. </li>
<li>Additional benefits and perks including:
<ul>
<li>A generous PTO program</li>
<li>A quality work life balance</li>
<li>Various wellness programs</li>
<li>Tuition Reimbursement</li>
<li>Professional development opportunities</li>
<li>Career development opportunities</li>
<li>Flexible scheduling</li>
<li>And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.</li>
</ul>
</li>
</ul>
 Our Work Environment: If located at the 500, 505 Building or a remote work location: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.</li>
<li>There are no harmful environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate.</li>
</ul>
 If located at PACE: 
<ul>
<li>Work is typically indoors in a clinical setting serving the frail and elderly.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 If located in the Community: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. </li>
<li>Employee will occasionally work outdoors in varied temperatures.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 Why Join Us? We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impacts on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare. What's Your Next Step? All Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. Do NOT miss out. If you want to join our team, the deadline for the first review of applications is December 9, 2025 at 9:00 PM (PST). We are encouraging you to apply early. If you apply after the first review date, your application is not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. Our Commitment to You Your application and resume will be reviewed by a dedicated recruiter to this position. If your experience matches what we need, we will reach out to you to discuss the next steps. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. If you make it through the steps above and are selected for this exciting role, you will be required to undergo a reference and a background check (to include a conviction record) and if applicable also pass a drug screening and/or a post-offer pre-employment medical examination (for specific positions) If you are an Internal CalOptima Health applicant, please apply through the internal portal on InfoNet. We will make sure to keep you updated through each step of the process on your candidate portal. Please make sure to watch for updates on your candidate portal and you emails which will be sent to the email address you listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. To apply, please visit: <a href="https://apptrkr.com/6757493" target="_blank">https://jobs.caloptima.org/jobs/member-liaison-specialist-customer-service-505-city-parkway-west-california-united-states-33e8b0be-b4dd-42d0-9530-e2df2d63a939</a> Copyright 2025 Jobelephant.com Inc. All rights reserved. <a href="https://www.jobelephant.com/" target="_blank">Posted by the FREE value-added recruitment advertising agency</a> jeid-537ce69475a85e4fb5e079ee955c18f2

Member Liaison Specialist (Customer Service)

TITLE: &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;ChiefTalent Officer
LOCATION: &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp;New York, NY (Lower EastSide)
DEPARTMENT: &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;Administration/Human Resources
REPORTS TO:&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp; &nbsp; Chief Executive Officer (CEO)
SALARY RANGE: &nbsp; &nbsp; &nbsp;&nbsp;&nbsp;$175,000 to $200,000 annually depending onexperience, plus excellent benefits
DATE POSTED: &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;July 2024

OUR CULTURE:&nbsp; At Grand St. we believeleaders are made, not born. &nbsp;We operate on auto trust,expecting staff will do their jobs well and continue to growprofessionally. &nbsp; We assume the best intentions and give gracewhenever needed. &nbsp; Diversity, equity, and inclusion areintegral parts of our culture and personified by our leadership.Grand St. is a community and we strive to make everyone –colleagues and constituents – feel supported and seen. &nbsp;
JOB SUMMARY:&nbsp; The Chief Talent Officer(CTO) provides executive-level leadership and guidance to theorganization’s HR strategies and operations for 600+ Union andManagement staff. The CTO is responsible not only for setting,enforcing, and evaluating legally compliant human resourcespolicies, procedures, and best practices, but also identifying andimplementing long-range strategic talent management goals. You willwork closely with the Executive Team performing all facets ofHR-related duties partnering with the Chief Financial Officer(CFO), Chief Program Officer of Youth &amp; Community Development,Chief Operating Officer (COO), Chief Development &amp;Communications Officer (CDCO), as well as senior management staff.&nbsp;This position carries out responsibilities in the followingfunctional and strategic areas: benefits administration, employeerelations, labor relations, training, performance management,onboarding, policy implementation, recruitment/employment,affirmative action and employment law compliance.&nbsp;
EDUCATION, EXPERIENCE AND SKILLREQUIREMENTS:
<ul>
<li>Masters preferred</li>
<li>Minimum of 10 years of Human Resource Management experiencerequired&nbsp;</li>
<li>HR Certification preferred</li>
<li>Strategic, Talent Management and/or Business Developmentexperience preferred</li>
<li>Knowledge of proven and emerging techniques in all aspects ofpersonnel management</li>
<li>Strong communication skills (both verbal and written)</li>
</ul>
<ul>
<li>Excellent supervisory, leadership, interpersonal and conflictresolution skills</li>
<li>Excellent organizational skills</li>
<li>Strong analytical and problem-solving skills</li>
<li>Thorough knowledge of employment-related laws andregulations</li>
<li>Experience with development and implementation of humanresource information and payroll systems</li>
<li>&nbsp;Experience with labor relations in a unionizedenvironment</li>
</ul>
Supervisory Responsibilities:
<ul>
<li>Supervises Management-level HR and Payroll staff</li>
<li>Oversees the daily workflow of the HR department and theadministration of human resource programs including, but notlimited to, compensation, benefits and leaves, disciplinarymatters, disputes and investigations, performance &amp; talentmanagement, evaluations, recognition, morale, occupational healthand safety, and training and development</li>
</ul>
ESSENTIAL DUTIES AND RESPONSIBILITIES:
<ul>
<li>Partners with the Executive Team to develop, implement andcommunicate human resource policies, procedures, laws, standardsand government regulations</li>
<li>Maintains the Employee Handbook</li>
</ul>
<ul>
<li>Collaborates with executive leadership to definethe&nbsp;organization's&nbsp;long-term mission and goals;identifies ways to support this mission through talentmanagement</li>
<li>Identifies key performance indicators (KPI’s) forthe&nbsp;organization's&nbsp;human resource and talent managementfunctions and assesses the&nbsp;organization's&nbsp;success andmarket competitiveness based on those metrics</li>
<li>Researches, develops, and implements competitive compensation,benefits, performance appraisal, and employee incentiveprograms</li>
<li>Oversees benefits administration including claims resolution,change reporting, approval of invoice payment, and communicatingbenefit&nbsp;information to employees</li>
<li>Ensures compliance with employment benefits, insurance, safety,401K, EEOC and other labor laws, regulations, and requirements</li>
</ul>
<ul>
<li>Administers and manages the 401K Plan</li>
</ul>
<ul>
<li>Maintains knowledge of laws, regulations, and best practices inemployment law, human resources, compensation and talentmanagement</li>
<li>Drafts and implements the&nbsp;organization's&nbsp;staffingbudget for the department.</li>
<li>Participates in professional development and networkingconferences and events.</li>
</ul>
<ul>
<li>Oversees department’s recruitment efforts including the postingof positions, recruitment advertising and other outreachpartnerships</li>
</ul>
<ul>
<li>Handles labor relations matters and coordination of thegrievance process</li>
</ul>
<ul>
<li>Monitors unemployment claims and assists with appeals onworkers’ compensation claims and coordinates between the employeeand insurance carrier</li>
<li>Responsible for Workers Compensation and 401k Audits</li>
<li>Performs other duties as required and assigned.</li>
</ul>
&nbsp;Your Skills &amp;Knowledge&nbsp;
<ul>
<li>Build a strong organizational culture that aligns with GrandStreet Settlement mission and implements all of those values onevery level of the organization</li>
<li>You take ownership of your work, think strategically, and takethoughtful action with very little direction</li>
<li>Excellent verbal and written communication skills</li>
<li>Excellent analytical and organizational skills</li>
<li>Extremely proficient with Microsoft Office Suite, Google Suiteor related software</li>
<li>People-centric and contributes to Grand St. Settlement’slegacy</li>
</ul>
BENEFITS:
<ul>
<li>Full medical insurance coverage</li>
<li>9% employer contribution to our 401k plan after 1 year</li>
<li>24 vacation days annually, 4 discretionary days, 12 sick daysannually</li>
<li>Guaranteed life Insurance and long-term disabilityinsurance</li>
<li>Flexible spending accounts</li>
<li>Travel/ commute reimbursement</li>
</ul>
HOW TO APPLY:
Please submit a resume and thoughtful cover letter outlining howyour skills &amp; experience meet the job descriptionto&nbsp;<a href="mailto:ctosearch@grandsettlement.org" target="_blank">ctosearch@grandsettlement.org</a>.Please include three professional references that we can contact;at least one should be a former supervisor.&nbsp;
If selected for this position, must obtain NYC Dept.of Health fingerprint clearance and State Central Registry (SCR)clearance (fees may apply); ability to maintain State CentralRegistry (SCR) clearance and fingerprint clearance throughout theduration of employment.
Employment Opportunity Employer (EOE)&nbsp;

Chief Talent Officer

<h3>Job Description</h3>
Job Description
Grievance &amp; Appeals (G&amp;A) Coordinator II Location: Alameda, CA (Hybrid – mostly WFH with occasional onsite meetings) Pay: $30-$35/hr, paid biweekly Start: 10/06/2025 - 06/26/2026 (This is a W2 contract assignment with opportunity to convert to direct based on attendance, performance, and business needs)
MUST have experience in health services, health insurance, hospital, or similar setting
About the Role
We are seeking a Grievance &amp; Appeals Coordinator II to join our team. In this role, you will review, investigate, and process non-complex grievances across multiple lines of business, while ensuring accuracy, compliance, and excellent member communication. You will work independently within a collaborative team environment and play a key part in ensuring quality service and regulatory compliance.
Key Responsibilities
<ul>
<li>Address and respond to telephonic and written inquiries regarding member non-complex grievances.</li>
<li>Investigate, research, review, and resolve grievances within regulated timeframes.</li>
<li>Interpret and apply policies, clinical guidelines, contracts, and regulatory requirements.</li>
<li>Communicate with members and providers throughout the grievance process.</li>
<li>Draft clear, professional written correspondence that meets regulatory standards.</li>
<li>Maintain accurate case documentation and database records.</li>
<li>Prepare and coordinate grievance documentation for State Fair Hearings, IMRs, and appeals.</li>
<li>Identify and escalate systemic issues impacting member care or service.</li>
<li>Manage a caseload of at least 60 cases per month while meeting quality and compliance standards.</li>
<li>Collaborate with internal departments to resolve member issues.</li>
<li>Participate in special projects as assigned.</li>
</ul>
Qualifications
<ul>
<li>High school diploma or equivalent (required). Associate’s or Bachelor’s degree (preferred).</li>
<li>2+ years of experience in health services, health insurance, hospital, or similar setting (required).</li>
</ul>
Skills &amp; Abilities
<ul>
<li>Knowledge of managed care and medical terminology.</li>
<li>Strong customer service and healthcare coordination background.</li>
<li>Excellent verbal and written communication skills.</li>
<li>Ability to handle sensitive information with confidentiality and accuracy.</li>
</ul>
Corrin Misak, Staffing Manager II A-Line Staffing Solutions <a href="mailto:cmisak@alinestaffing.com" target="_blank">cmisak@alinestaffing.com</a>

Grievance and Appeals Coordinator

<h3>Job Description</h3>
Job Description
BCforward is currently seeking a highly motivated Grievance &amp; Appeals Coordinator for an opportunity in Remote who reside in Georgia
Position Title: Grievance &amp; Appeals Coordinator
Location: Remote in Georgia
Expected Duration: 12 months contract or 3 months convert into FTE
Pay Rate: $22.50/hr on w2
Education level: HIGH School/GED or Associates
Anticipated Start Date: ASAP
Shift : 8:00am – 5:00pm EST Monday – Friday

********Remote to Georgia - Candidates must reside in GA**********

Job Description:
<ul>
<li>Analyze and resolve verbal and written claims and authorization appeals from providers, and pursue resolution of formal grievances from members.</li>
</ul>
Education/Experience:
<ul>
<li>High school diploma or equivalent required; Associate’s degree preferred.</li>
<li>2+ years of grievance or appeals, claims, or related managed care experience.</li>
<li>Strong oral, written, and problem-solving skills.</li>
</ul>

Responsibilities:
<ul>
<li>Gather, analyze, and report verbal and written member and provider complaints, grievances, and appeals.</li>
<li>Prepare response letters for member and provider complaints, grievances, and appeals.</li>
<li>Maintain files on individual appeals and grievances.</li>
<li>Coordinate the Grievance and Appeals Committee as needed.</li>
<li>Support pay-for-performance programs, including data entry, tracking, organizing, and researching information.</li>
<li>Assist with HEDIS production functions, including data entry, provider office calls, and claims research.</li>
<li>Manage large volumes of documents, including copying, faxing, and scanning incoming mail.</li>
</ul>
Benefits:
BCforward offers all eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k.
Company DescriptionAbout BCforward: Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward’s 6,000 consultants support more than 225 clients globally. BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class places to work. BCforward is an equal opportunity employer. 
<h3>Company Description</h3>
About BCforward:\r\n\r\nFounded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward’s 6,000 consultants support more than 225 clients globally.\r\n\r\nBCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class places to work.\r\n\r\nBCforward is an equal opportunity employer.

<h3>Job Description</h3>
**OPEN ONLY TO THOSE WHO RESIDE IN ARIZONA**
 
CORE FUNCTIONS:
<ol>
<li>Maintains State Fair Hearing Logs with appropriate information required by HP policy, AHCCCS, HCG, and CMS regulations.</li>
<li>Reviews all State Fair Hearing requests by members and providers, pulls case files, meets with Grievance &amp; Appeals Manager for further review and action, which may include collaboration with others to avoid/reduce grievances, appeals, and/or claim disputes. May attend State Fair Hearings.</li>
<li>Coordinates and assists the Grievance &amp; Appeals Manager in preparing for higher levels of appeals (i.e., Independent Review Entity reviews, hearings, etc.), including telephonic requests.</li>
<li>Assists with project management of departmental improvements. Coordinates with other departments on Grievance &amp; Appeals projects/workgroups.</li>
<li>Assists the Marketing Department with the production of all member letters and notices. Participates actively in meetings, workgroups, and committees relevant to the Grievance &amp; Appeals process. May produce, prepare, quality check, or deliver all reporting requirements in the absence of the Grievance &amp; Appeals Manager.</li>
<li>Produces and analyzes weekly and monthly data to determine trends and provides recommendations for intervention. Assists with internal, external, and self-audits of the department and annual data validation.</li>
<li>Produces a Monthly Operational Dashboard. Produces, analyzes, and reports monthly data to ensure regulatory compliance. Updates Grievance &amp; Appeals data in conjunction with the Marketing department on all HP websites.</li>
<li>Monitors and resolves member and provider expedited appeals and grievances received after hours and/or holidays when assigned to rotational on-call duty. Coordinate appropriate action by supporting clinical staff for processing of member and provider expedited appeals and/or grievances.</li>
<li>This position works under supervision, prioritizing data from multiple sources to provide quality care and support. Incumbents work in a fast-paced, sometimes stressful environment with a strong focus on customer service. Interacts with staff at all levels throughout the organization.</li>
</ol>
 
MINIMUM QUALIFICATIONS:
<ul>
<li>High school diploma/GED or equivalent working knowledge. Two years of work experience in a health care related field or experience managing projects/initiatives, or an equivalent combination of education and experience</li>
<li>Three to four years of grievance and appeal work in a health care environment, or an equivalent combination of education and experience. Maintains knowledge of AHCCCS, HCG, and CMS regulations by participating in training, teleconferences, and services.</li>
</ul>

Senior Grievance and Appeals Coordinator

<h3>Job Description</h3>
Job Description
Title:&nbsp; Appeal &amp; Grievance Coordinator
Customer Service Specialist- Appeals and Grievance coordinator -Remote Location:&nbsp; Remote &nbsp;
JOB SUMMARY
This job reviews inquiries to determine if they meet the definition of a grievance/appeal; documents, investigates, refers and coordinates grievances and appeals; initiates a case file for each grievance and appeal; ensures compliance with organizational and regulatory requirements for member or provider issues; independently coordinates the resolution with internal/external parties as required; and documents and summarizes to all parties involved in the case the investigation results. ESSENTIAL RESPONSIBILITIES • Review inquiries to determine if they meet definition of appeal/grievance. • Request and review all related relevant documentation and assemble case file. • Coordinate resolution results and relay investigative results with all involved parties. Participate in workgroup meetings to address trends in appeals and grievances and to work on process improvement initiatives with cross functional teams to reduce trends. •• May support the Quality Assurance, Appeal and other quality committees. • Other duties as assigned or requested. EDUCATION Required • High School Diploma or GED EXPERIENCE Required 3-5 years of relevant, progressive experience in the area of specialization.&nbsp; Preferred • Experience in Customer Service or a related field SKILLS • Knowledge of multiple processing systems and workflows • Knowledge of claims processing methodologies • Ability to interpret all government regulations&nbsp; Excellent organizational skills • Strong verbal and written communication skills
Company DescriptionAbout PRSG® – At Precision Recruiting Solutions Group®, we're all about you – the Accounting, Finance, and HR professionals. We specialize in understanding your career goals and values, matching you with tailored opportunities that align with your expertise. Our dedicated focus ensures you find employers who recognize and value your exceptional skills. Elevate your career in Accounting, Finance, or HR with us. 
<h3>Company Description</h3>
About PRSG® – At Precision Recruiting Solutions Group®, we're all about you – the Accounting, Finance, and HR professionals. We specialize in understanding your career goals and values, matching you with tailored opportunities that align with your expertise. Our dedicated focus ensures you find employers who recognize and value your exceptional skills. Elevate your career in Accounting, Finance, or HR with us.

Appeals and Grievance Coordinator -Remote CSR

<h3>Job Description</h3>
Immediate need for a talented Appeals and Grievance Coordinator in California. This is a 06+ months contract opportunity with long-term potential and is located in Los Angeles County, CA (Remote). Please review the job description below and contact me ASAP if you are interested.
 
Job ID: 25 65809
 
Pay Range: $26 - $30/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).
 
Key Responsibilities:
 
<ul>
<li>Manage and investigate member appeals and grievances received via email and phone.</li>
<li>Review and evaluate claims and medical billing documentation to support appeal decisions.</li>
<li>Ensure all cases are handled in compliance with regulatory standards and internal policies.</li>
<li>Accurately document communications and outcomes within case management systems.</li>
<li>Communicate clearly and empathetically with members to resolve concerns efficiently.</li>
</ul>
 
Key Requirements and Technology Experience: 
 
<ul>
<li>Key Skills- Strong Case management experience with Inpatient acute care (Hospital) Experience within Appeals and Grievance, Utilization and conducting investigations.</li>
</ul>
 
 
Our client is a leading Healthcare Industry, and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.
 
Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
 
By applying to our jobs you agree to receive calls, AI-generated calls, text messages, or emails from Pyramid Consulting, Inc. and its affiliates, and contracted partners. Frequency varies for text messages. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. You can reply STOP to cancel and HELP for help. You can access our privacy policy here.

Appeals and Grievance Coordinator in California

<h3>Job Description</h3>
Job DescriptionAs an Appeals and Grievances Coordinator you'll play a crucial role in efficiently processing appeal and grievance requests, ensuring smooth operations, and maintaining excellent communication. Responsibilities:
<ul>
<li>Support the team in processing appeal and grievance requests promptly and efficiently.</li>
<li>Communicate effectively with the team about special projects and priorities.</li>
<li>Monitor and distribute incoming faxes and emails to the appropriate departments.</li>
<li>Review and prioritize written appeals and grievances.</li>
<li>Enter and document new appeals or grievances received via various channels.</li>
<li>Assist in obtaining additional information and follow-up as needed.</li>
<li>Maintain accurate documentation of all communications and actions.</li>
<li>Coordinate meetings, including scheduling, invites, agendas, and minutes.</li>
<li>Provide administrative support to the Appeals and Grievances Supervisor and Utilization Operations Director.</li>
</ul>
Qualifications:
<ul>
<li>High School Diploma.</li>
<li>6 months of experience in an administrative role.</li>
<li>A minimum of 1 year of previous experience in the healthcare industry and with Facets and Salesforce is a plus.</li>
<li>Intermediate computer skills, including email, database activity, word processing, and spreadsheets.</li>
</ul>
Sacramento, CA 95833 Monday to Friday 8am - 5pm potential to go hybrid Pay Details: $20.00 to $24.00 per hour Search managed by: Joanna Calderon Benefit offerings available for our associates include medical, dental, vision, life insurance, short-term disability, additional voluntary benefits, EAP program, commuter benefits and a 401K plan. Our benefit offerings provide employees the flexibility to choose the type of coverage that meets their individual needs. In addition, our associates may be eligible for paid leave including Paid Sick Leave or any other paid leave required by Federal, State, or local law, as well as Holiday pay where applicable. Equal Opportunity Employer/Veterans/Disabled Military connected talent encouraged to apply To read our Candidate Privacy Information Statement, which explains how we will use your information, please navigate to <a href="https://www-uat.lhh.com/us/en/candidate-privacy" target="_blank">https://www-uat.lhh.com/us/en/candidate-privacy</a> The Company will consider qualified applicants with arrest and conviction records in accordance with federal, state, and local laws and/or security clearance requirements, including, as applicable:
<ul>
<li>The California Fair Chance Act</li>
<li>Los Angeles City Fair Chance Ordinance</li>
<li>Los Angeles County Fair Chance Ordinance for Employers</li>
<li>San Francisco Fair Chance Ordinance</li>
</ul>
Massachusetts Candidates Only: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Appeals and Grievance Specialist

<h3>Job Description</h3>
Job DescriptionSummary Description:
The Pharmacy Technician works closely with Western Health Advantage’s (WHA) Chief Pharmacy Officer, Pharmacy Manager, Medical Directors, Clinical Pharmacists and Pharmacy Coordinator to ensure pharmacy utilization management review functions are carried out effectively at the health plan level. The Pharmacy Technician may work with several internal departments to assist with pharmacy related benefit interpretation, provide pharmacy related assistance, and provide problem solving on appeal and grievance cases as needed. This position also evaluates and performs utilization review of prescription medication requests under the protocols and criteria developed by the Chief Pharmacy Officer, Pharmacy Manager and Clinical Pharmacists. This position assists in creating as well as updating and maintaining current written procedures for the team.
Representative Duties:
• Perform authorization review of prescription medication requests utilizing established protocols and criteria developed by the Pharmacy leaders and Clinical Pharmacists, transferring all clinical questions and judgements falling outside the standardized criteria to the Clinical Pharmacists for review.
• Coordinate with Pharmacy Coordinator and other internal departments to ensure authorization decisions and notifications to members and providers are completed in compliance with regulatory requirements.
• Assist Member Service Representatives and Individual Plan Administrators/Medical Group staff with interpretation of pharmacy benefits and criteria.
• Research, review, and when indicated, prepare cases for Pharmacy leaders, Pharmacist, and/or Chief Medical Officer review, and ensure timely and appropriate follow-up by creating and sending authorization/approval or denial letters.
• Assist in maintaining the WHA Formulary Drug List and Pharmacy Prior Authorization (PA) Criteria per the Pharmacy and Therapeutics (P&amp;T) Committee decisions.
• Assist Pharmacy leaders with accreditation audits by the Department of Managed Health Care (DMHC) regulatory and National Committee of Quality Assurance (NCQA).
• Assist Pharmacy leaders with pharmacy/PBM related audit tasks.
• Ensure timely creation and processing of denial letters for cases denied by Clinical Pharmacists.
• Maintain current knowledge of medications and drug classifications.
• Responsible for helping support administrative functions such as notifications to providers, members and supporting return mail process.
• Support development of Pharmacy policy procedures, training material, and desk level procedures.
• Work with the Pharmacy leaders to ensure there is appropriate coverage beyond regular business hours to ensure all cases are completed to comply with regulatory requirements.
• Experienced Pharmacy Technicians are responsible for mentoring and/or training new and less experienced Pharmacy Technicians and Pharmacy Coordinators and serve as resources in answering questions.
• Support, review, and research pharmacy related cases for Appeals and Grievances.
• Responsible for helping support administrative functions such as notifications to providers and members, and processing returned mail.
• Perform other duties and special projects as assigned.
Qualifications:
• High School Diploma.
• Three years of experience as Pharmacy Technician.
• Two years of experience working in a utilization/managed care environment.
• One year of experience working in a customer service or call center environment is highly desired.
• Must have valid California Pharmacy Technician License in good standing and must be maintained throughout employment.
• Experience with writing in business correspondence style.
• Intermediate computer skills, including electronic mail, routine database activity, word processing, spreadsheet, graphics, etc.
• Must be able to speak, read, write, and understand the primary language(s) used in the workplace.
Salary:
$21.00 - $26.00 Hourly (EOE)
 Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law.
Western Health Advantage values and supports the unique talents and strengths that each employee brings to our organization. Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you — and excellent customer service for our members.
 *WARNING: Please beware of phishing scams that solicit interviews or promote work-at-home opportunities, some of which may pose as legitimate companies. Please be advised that Western Health Advantage will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the to the Federal Trade Commission by selecting the ‘Rip-offs and Imposter Scams’ option.’
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Pharmacy Technician

<h3>Job Description</h3>
Job DescriptionSummary Description:
The Appeals &amp; Grievances Specialist I is responsible for knowledge of WHA’s practices, processes, policies and procedures, benefit guidelines, and contractual agreements. This position is also responsible for meeting all regulatory guidelines and timeframes with regards to appeal and grievance (complaint) case processing for Western Health Advantage (WHA). This includes, but is not limited to, maintaining knowledge of the CA Department of Managed Healthcare (DMHC) regulations and the National Committee for Quality Assurance (NCQA) credential standards for accreditation pertaining to appeals and grievances, as well as Privacy Practices for the Use and Disclosure of Protected Health Information (PHI) regulations, with regards to member information and medical records. This is a fast-paced position that involves extensive interaction with internal departments, external entities, to include medical groups, providers, an authorized representative, or broker.
Representative Duties:
• Serve as the assigned specialist to perform intake, research and investigation of member issues that are related to appeals and/or grievances, while effectively representing the member’s interest from initial triage.
• Quickly learn and retain appeals and grievances classifications, which include, but are not limited to, a request to change an initial decision or modification, or to grieve, with regard to enrollment/disenrollment, premium billing, access and care coordination, service, medical and prescription benefits and prior authorizations, claims processing, medical and prescription reimbursement requests, deductibles and out-of-pocket maximums, utilization management, quality of care, legal/compliance matters, or any aspect related to their health plan or its delegated entities.
• Identify urgency of a case, screening of an expedited request, recognition of a potential quality issue, violation of PHI/HIPAA, medical fraud, breach of contract or when a request exceeds the statutes of limitations.
• Perform outreach to members or authorized representative(s), when necessary, to obtain additional information and clarification in relation to the grievance/appeal.
• Promptly perform intake utilizing multiple systems for initial intake and research.
• Triage and task to next level of support or to the appropriate clinical staff for further review.
• Perform outreach and provide notification to members regarding expedited requests and whether or not it met criteria, followed by their rights to contact the DMHC.
• Work with WHA’s internal departments, contracted medical groups, and hospital systems to request all pertinent information relevant to the member’s appeal/grievance.
• Evaluate information received from appropriate departments or entities to ensure that the information provided is sufficient for a Plan determination.
• Perform follow-up on appeals and/or grievances, as assigned, and contact the appropriate departments or entities (internal or external) for a thorough response.
• Maintain accurate and thorough documentation of outreach, communications, medical records and chart notes, decisions, and appeal review committee actions.
• Customize all written acknowledgement letters to summarize the member’s request.
• Assist with resolution letters to include case specifics which are established and based on a determination of benefit guidelines and/or medical necessity, to include education to members.
• Report possible trends or increased issues when identified during intake.
• Participate and engage in process improvement plans, to include training improvement opportunities.
• Effectively communicate with team members and provide support to A&amp;G staff that have increased responsibilities.
• Provide support to the A&amp;G Coordinator, to include backup with monitoring and handling of incoming/outgoing email, mail, and faxes.
• Perform other duties and special projects as assigned
Qualifications:
• High School Diploma.
• 2 years’ experience in a similar role (appeals and grievances) in the healthcare industry; preferably HMO, with increased responsibilities.
• Experience with HMO claims adjudication, as well as referrals and authorizations (utilization management), are preferred.
• Intermediate computer skills, including electronic mail, routine database activity, word processing, spreadsheet, graphics, etc. Specifically, Microsoft Word and Excel.
• Must be able to speak, read, write (intermediate writing skills), and understand the primary language(s) used in the workplace.
Salary:
$22.00- $25.00 Hourly
Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law. (EOE)
Western Health Advantage values and supports the unique talents and strengths that each employee brings to our organization. Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you — and excellent customer service for our members.
 *WARNING: Please beware of phishing scams that solicit interviews or promote work-at-home opportunities, some of which may pose as legitimate companies. Please be advised that Western Health Advantage will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the to the Federal Trade Commission by selecting the ‘Rip-offs and Imposter Scams’ option.’
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34 grievance-and-appeals-coordinator Jobs