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Grievance Resolution Specialist 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 Grievance Resolution Specialist and help shape the future of healthcare where you'll be an integral part of our Grievance &amp; Appeals 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. This position has been approved to be Full Office. 
<ul>
<li> If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum. </li>
</ul>
 You will be responsible for coordinating the grievance and appeal resolution process. You 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. You will have frequent external contact with members and families, health care providers, health networks, third party administrators and regulators. You 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. Together, we are building a stronger, more equitable health system. Your Contributions To the Team: 
<ul>
<li>80% - Program 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>Maintains adequate information in CalOptima Health's systems; ensures data collection, summarization, integration and reporting, including case creation and management and events/activity tracking.</li>
<li>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.</li>
<li>Coordinates and participates in case discussions with operational experts to result in a final case disposition as needed.</li>
<li>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.</li>
<li>Develops resolution letters and correspondence to members and providers.</li>
<li>Communicates with internal and external customers to ensure timely review and resolution of grievances or appeals.</li>
<li>Initiates referrals to the Quality Improvement department as applicable and facilitates responses to members according to CalOptima Health policy. </li>
</ul>
</li>
<li>15% - Administrative Support
<ul>
<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>Assists with health networks' compliance process.</li>
<li>Meets performance measurement goals for Grievance and Appeals Resolution Services (GARS).</li>
<li>Identifies trends and root cause of issues, proposes solutions, or escalates ongoing issues to management. </li>
</ul>
</li>
<li>5% - Completes other projects and duties as assigned. </li>
</ul>
 Do You Have What the Role Requires? 
<ul>
<li>High school diploma or equivalent PLUS 1 year of experience in 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.</li>
</ul>
 You'll Stand Out More If You Possess the Following: 
<ul>
<li>Associate degree in business, health care administration or related field. </li>
<li>Experience in health care practice standards for both government and commercial plans. </li>
<li>Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, 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: 304 - $53,813 - $80,720 ($25.87 - $38.8077). 
<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=6824005&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 31, 2026 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/6824005" target="_blank">https://jobs.caloptima.org/jobs/grievance-resolution-specialist-505-city-parkway-west-california-united-states-132a29ad-c6dc-41d4-83e2-463f783089a5</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-b91eeef896b1c44e908896c55c9a9cbb

Grievance Resolution Specialist

Grievance &amp; Appeals Nurse Specialist 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 Grievance &amp; Appeals Nurse Specialist and help shape the future of healthcare where you'll be an integral part of our Grievance &amp; Appeals 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. This position has been approved to be Full Telework. 
<ul>
<li> If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum. </li>
</ul>
 You will participate in managing CalOptima Health's medical appeals and state hearing reviews for all lines of business, including handling expedited and standard requests. You will ensure appeals and state hearing requests are processed in accordance with regulations, compliance standards and policies and procedures. You will investigate and prepare case narratives and statements of position based on clinical information, benefits and applicable regulations related to member or provider disputes of decisions. You will clearly articulate the facts and CalOptima Health's position regarding disputes to the Administrative Law Judge hearing the case. You will be responsible for creating and reviewing resolution letters for appropriateness of clinical criteria and regulatory requirements. Together, we are building a stronger, more equitable health system. Your Contributions To the Team: 
<ul>
<li>80% - Program 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>Prepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions.</li>
<li>Ensures all cases are completed in accordance with state and federal regulatory requirements including timelines.</li>
<li>Presents recommendations based on clinical review, criteria and organizational policies to CalOptima Health's physician reviewers for final determination.</li>
<li>Resolves complex and sensitive member issues within established timelines.</li>
<li>Maintains departmental database and the integrity of records by accurately entering case actions to assigned cases.</li>
<li>Analyzes and reports cases through GARS' subcommittee.</li>
<li>Oversees state hearing cases.</li>
<li>Assists with the notification process to members or providers on the clinical decision issued.</li>
<li>Discusses appeal process, medical decisions and hearing rights with members.</li>
<li>Assists members in coordinating their services with providers and communicates the status and outcome to members.</li>
<li>Assigns position statements and represents CalOptima Health at state hearings. </li>
</ul>
</li>
<li>15% - Administrative Support
<ul>
<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>Participates in departmental meetings, trainings and audits as requested. </li>
</ul>
</li>
<li>5% - Completes other projects and duties as assigned. </li>
</ul>
 Do You Have What the Role Requires? 
<ul>
<li>High school diploma required PLUS 5 years of health care/managed care experience required, preferably in the following related areas of responsibility: grievances and appeals, utilization management and/or quality management; 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>Current unrestricted Registered Nurse (RN) license to practice in the state of California. </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>Current unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California.</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: 313 - $90,820 - $145,312 ($43.66 - $69.8615). 
<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 Telework (**If the position is Telework, it is eligible in California only**) </li>
<li>A <a href="https://apptrkr.com/get_redirect.php?id=6827312&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 January 13, 2026 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/6827312" target="_blank">https://jobs.caloptima.org/jobs/grievance-appeals-nurse-specialist-505-city-parkway-west-california-united-states-15e815c2-3fcd-4db0-a51e-8078f72ffc27</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-6b482c6ee7f7164a8ac6b7e408651c04

Grievance & Appeals Nurse Specialist

Social Worker (PACE) (Bilingual in Spanish) 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 Social Worker Bilingual in Spanish and help shape the future of healthcare where you'll be an integral part of our PACEC - Social Work 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. This position has been approved to be Full Office. 
<ul>
<li> If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum. </li>
</ul>
 You, as the Social Worker for the Program for All-Inclusive Care for the Elderly (PACE) will be responsible for direct social work care management services, such as participant screening, case management, counseling and referrals of participants to PACE. Together, we are building a stronger, more equitable health system. Your Contributions To the Team: 
<ul>
<li>70% - Care Management
<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>Participates in the Interdisciplinary Team's (IDT) initial, six (6) month and annual assessments, as well as care planning of the participant's case in accordance with industry and departmental standards. </li>
<li>Documents participant changes appropriately in the medical record in accordance with industry and departmental standards. </li>
<li>Communicates effectively and openly with other IDT members on participant status and needs.</li>
<li>Assesses patients for high-risk situations such as suicidal/homicidal ideation and abuse. Reports appropriately in accordance with legal and ethical standards of practice and engages in safety planning with participants and/or family. </li>
<li>Develops and leads group counseling and participant support group activities. </li>
<li>Refers participants and families to appropriate community agencies or facilities, serves as a liaison with such organizations and as an advocate for participants.</li>
<li>Assists in the completion of advance directives, mortuary arrangements, funeral planning and/or facility placement. </li>
<li>Aids patients/representatives in ascertaining third-party and financial resources and planning for financial coverage for services as necessary. </li>
<li>Addresses any psychosocial needs that may require social work support and intervention (e.g., anxiety, depression and other behaviors), both at the center and at home. </li>
<li>Works with PACE participants and the IDT to develop an appropriate discharge plan for disenrolling from PACE services.</li>
<li>May be required to perform home visits to private homes of CalOptima Health's PACE participants; frequent travel in Orange County. </li>
<li>Support PACE participants with care coordination needs, such as transportation, family communication, scheduling visits to the center, supporting with warm handoff process to our community partners. </li>
<li>Represents and supports the participant's care management needs by being an advocate for their care, supporting clinical needs such as supportive counseling, developing care plans to manage all psychosocial needs (i.e., establishing support systems, coping mechanisms, assessing depression, anxiety, cognition) and developing interventions. </li>
</ul>
</li>
</ul>
<ul>
<li>25% - Support Services
<ul>
<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>Consults with and advises staff members regarding the relationship of social, emotional and cultural factors to health and medical care and the availability of social services in the community. </li>
<li>Attends and participates in in-services, staff meetings and case conferences. Helps support the new enrollee process of enrollment into the PACE program (e.g., communicates to IDT and ensures all service gaps are covered prior to enrollment). </li>
<li>Participates in program improvement for the Social Work department. </li>
<li>Works with the Quality Improvement (QI) department to support grievances, appeals and advocacy consistent with participant's rights. </li>
</ul>
</li>
</ul>
<ul>
<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>Master's degree in social work from an accredited college or university PLUS 2 years of experience in a health-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. </li>
<li>1 year of experience working with the elderly population with relevant experience within the last 3 years required. </li>
<li>CPR and First-Aid Certification required or must be obtained within six (6) months of the date of hire. </li>
<li>Bilingual in English and in one of CalOptima Health's defined threshold languages (Spanish). </li>
<li>Valid driver's license and vehicle or other approved means of transportation, an acceptable driving record and current auto insurance will be required for work away from the primary office 30% of the time or more.</li>
</ul>
 You'll Stand Out More If You Possess the Following: 
<ul>
<li>1 year of case management experience with the elderly population. </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: 309 - $68,015 - $108,824 ($32.70 - $52.3192). 
<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=6838638&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 January 20, 2026 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/6838638" target="_blank">https://jobs.caloptima.org/jobs/social-worker-pace-bilingual-in-spanish-pace-garden-grove-california-united-states</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-28aaeb01aa820543b42b01ac90c5fe90

Social Worker (PACE) (Bilingual in Spanish)

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 Description
13666-1 , Remote Appeal and Grievance Coordinator, Pittsburgh, PA - 4+ Months, Contract to hire Sigma Systems Inc is looking to hire a Appeal and Grievance Coordinator for their client. Due to the governmental nature of these positions, only US Citizens are eligible to apply. Shift Details: M-F (8-hr shift that will start between 7am -9am) Responsibilities:
<ul>
<li>Receive, investigate and triage expedited appeal requests received from Client members/member and provider representatives enrolled in Senior Products. </li>
<li>Timely assignment of cases is critical to ensure member's and/or provider's appeal rights are processed in accordance with regulatory agencies' standards, including the Center for Medicare and Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA). </li>
<li>Claims research and processing (more of researching why the claim was denied than actually researching into the claim) </li>
<li>Authorization lookup/ building authorizations as well as updating authorizations </li>
<li>Researching outside vendor sites for authorizations and review of notes </li>
<li>Reviewing appeal letters to determine what the provider is appealing </li>
<li>Responsible for starting the appeal process and researching the appeal. Responsible for sending out appeal determination letters and completing the appeal. </li>
<li>Extensive training on internal and external systems and the internal appeal process </li>
</ul>
Requirements:
<ul>
<li>At least 1 year of experience in health insurance claims and appeals is strongly preferred </li>
<li>At least a HS degree, but a college degree and/or extensive experience would be considered. </li>
<li>Outbound call experience (though not a large part of this job) is a good to have. </li>
<li>A customer service background and experience, not necessarily in the healthcare field, is a nice to have as well. </li>
<li>Medicaid experience desired and will make the candidate stand out. </li>
<li>The job receives, researches and correctly classifies all grievance and appeals cases. </li>
<li>This includes any escalated step of the grievance and appeals process in accordance with state and federal regulatory requirements and state and federal regulations set forth for government products. </li>
<li>Must have prior claims or appeals work history </li>
</ul>

40 grievance-and-appeals-coordinator Jobs