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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 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=6687129&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 November 11, 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/6687129" target="_blank">https://jobs.caloptima.org/jobs/member-liaison-specialist-customer-service-505-city-parkway-west-california-united-states-c3fb6d6c-517c-418f-8d64-895099286932</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-de8018e655f9b64388465261ce5f3fed

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 DescriptionSalary: 
Job Summary: 
SafeRide Health is seeking an experienced Complaints and Grievance Coordinator responsible for processing complaints and grievances, consisting of member grievances, appeals, and provider disputes. This role ensures that cases are resolved by client-specific requirements across all lines of business.
 
Primary Responsibilities
<ul>
<li>Maintain contractual compliance and customer satisfaction</li>
<li>Ensure that all assigned complaints and grievances are completed by the deadline and other contractual requirements</li>
</ul>
<ul>
<li>Respond to Comment Letters and client inquiries and requests</li>
</ul>
<ul>
<li>Ensure interactions remain positive and professional with all persons with whom you and the Complaints and Grievance Team interact in the course of your work, both internally and externally</li>
</ul>
<ul>
<li>Researching the details and history of a case and creating a clear timeline of events</li>
</ul>
<ul>
<li>Communicating, both orally and in writing, with members and providers as needed</li>
</ul>
<ul>
<li>Updating members and providers regarding the progress of active and open cases</li>
</ul>
<ul>
<li>Requesting, reviewing, sorting, and preparing data related to complaints and grievances</li>
</ul>
<ul>
<li>Working with relevant departments to complete all necessary follow-up and research</li>
</ul>
<ul>
<li>Complaint and grievance escalations</li>
<li>Interdepartmental and Client Communication</li>
</ul>
<ul>
<li>
<ul>
<li>Provide daily, weekly and monthly complaint and grievance updates to leadership</li>
</ul>
</li>
</ul>
<ul>
<li>
<ul>
<li>Recommend solutions and work with internal department leadership to ensure problems are corrected, and departments are advised of corrective measures to prevent recurrences</li>
</ul>
</li>
</ul>
<ul>
<li>
<ul>
<li>Provide complaint and grievance data to leadership regarding provider complaint and grievance trends</li>
</ul>
</li>
</ul>
<ul>
<li>Other duties as assigned</li>
</ul>
 
Required Education and Experience:
<ul>
<li>Minimum High school diploma or equivalent</li>
</ul>
<ul>
<li>Minimum one (1) year in grievance and appeals processing</li>
</ul>
<ul>
<li>Minimum one (1) year in an inbound call center environment</li>
</ul>
 
Preferred Education and Experience
<ul>
<li>Experience with Medicaid, Medicare, and NEMT guidelines </li>
</ul>
<ul>
<li>Associates degree in relevant discipline</li>
</ul>
<ul>
<li>Knowledge of health insurance programs and benefits</li>
</ul>
 
Skills
<ul>
<li>Customer-oriented with the ability to address customers needs while following company procedures.</li>
</ul>
<ul>
<li>Outstanding problem-solving skills and ability to use soft skills in a high-stress environment</li>
</ul>
<ul>
<li>Strong analytical skills and the ability to use thinking and logic to solve everyday issues</li>
</ul>
<ul>
<li>Personable, with solid leadership and mentoring skills</li>
</ul>
<ul>
<li>Strong communication skills (both verbal and written) and demonstrated ability to communicate, present, and influence effectively in person, via email, and over the phone</li>
</ul>
<ul>
<li>Ability to meet contractual reporting requirements and deadlines</li>
</ul>
<ul>
<li>Ability to adapt to unforeseen circumstances quickly</li>
</ul>
<ul>
<li>Ability to respond to sensitive or complex issues with tact and sensitivity</li>
</ul>
<ul>
<li>Proficiency in listening and problem-solving skills</li>
</ul>
<ul>
<li>Ability to establish and maintain effective working relationships with members, coworkers, providers, and individuals of varying socio-economic and cultural backgrounds and with special needs populations</li>
</ul>
<ul>
<li>Ability to effectively, clearly, and independently document, summarize and resolve members concerns and inquiries</li>
</ul>
 
About Us:
SafeRide Health is a technology and services company dedicated to reducing barriers to care by improving the delivery of non-emergency medical transportation to people across America. SafeRide Health leverages proprietary technology and a nationwide network of vetted transportation providers to give payers and health systems a more intelligent way to deliver cost-effective, on-demand transportation while improving the patient experience. SafeRide serves the largest Medicare Advantage, Medicaid, and provider programs in the country. Learn more at<a href="http://www.saferidehealth.com" target="_blank">www.saferidehealth.com</a>.

Complaints and Grievance Coordinator

<h3>Job Description</h3>
Job Description
The Pharmacy Technician is responsible for answering member, pharmacy, and provider questions as well as researching and resolving problems, to help members understand and optimize the use of their pharmacy benefit. Pharmacy Technicians also work with pharmacists to help review drug coverage requests from members, physicians, and pharmacies to determine medication coverage based on benefit plan design, client specifics, clinical notes, and clinical criteria according to the utilization management system(s).
Required:
<ol>
<li>High School diploma or equivalent.</li>
<li>National Pharmacy Technician Certification </li>
<li>One year experience in a retail, hospital, managed care, or other similar pharmacy setting.</li>
<li>Minimum typing speed of 35 words per minute</li>
<li>Demonstrate working knowledge of direct claims processing, pharmacy computer systems, spreadsheet applications (i.e., Microsoft Excel), phone system and other office/computer equipment as required.</li>
<li>Knowledge of pharmaceutical generic and trade names.</li>
<li>Ability to comprehend and follow established office routines, policies, and procedures.</li>
<li>Effective oral and written communication skills, including grammar and spelling.</li>
<li>Strong organizational skills, time management and multi-tasking abilities.</li>
<li>Detail oriented with advanced analytical and problem-solving skills.</li>
<li>Ability to work effectively as part of a team and independently.</li>
<li>Provide excellent customer service.</li>
<li>Follow all plan policies and procedures.</li>
</ol>
Desired:
<ol>
<li>Degree in health-related field.</li>
<li>Experience performing medication authorizations in pharmacy or managed care environment.</li>
</ol>
Responsibilities:
<ol>
<li>Completes medication coverage requests through prior authorization criteria and escalates requests to Clinical Pharmacists or Medical Directors when requests require clinical review or is not approvable through the automated system.</li>
<li>Contacts providers to obtain all necessary information for coverage requests prior to referring cases to Clinical Pharmacists or Medical Directors.</li>
<li>Attaches relevant policy(ies) for the medication requests to the case documents prior to referring cases to Clinical Pharmacists or Medical Directors.</li>
<li>Identifies and documents the relevant policy information prior to referring cases to a Clinical Pharmacist or Medical Director for review.</li>
<li>Resolves and documents coverage request outcomes in pharmacy benefit manager's system and communicates decision to physician's office and/or members through verbal and/or written notification in accordance with company policies.</li>
<li>Researches, resolves, and documents physician or member inquiries and grievances and documents outcomes in the pharmacy benefit manager's system, medical review system or customer service tool in an accurate and timely manner.</li>
<li>Provides verbal verification of member's plan eligibility and applicable pharmacy benefits.</li>
<li>Utilizes pharmacy benefit manager and medical review system to update, modify and extract member information.</li>
<li>Details members and providers on pharmacy benefit inquiries such as formularies and pharmacy networks.</li>
<li>Assists pharmacies in processing prescription claims; review and troubleshoot claims for accuracy and adherence to contract guidelines.</li>
<li>Consults with clinical pharmacists for guidance and assist if necessary.</li>
<li>Gathers clinical documentation necessary for the performance of medication reconciliation and yearly medication reviews and refers documentation to a Care Management Pharmacist for review.</li>
<li>Identifies and documents peer-to-peer requests and refers cases to a Clinical Pharmacist or Medical Director for review.</li>
<li>Interacts with staff, customer service and supervisors to ensure best practices.</li>
<li>Follows policy and procedures pertaining to all lines of business.</li>
<li>Ensures turnaround times meet requirements with company, state, and federal regulations.</li>
<li>Meets internal key performance indicators as defined in The Health Plan’s Policies and Procedures.</li>
<li>Explains Appeal and Grievance process to members and providers.</li>
<li>Identifies, documents, and sends appeal requests to the Appeals and Grievances Department per Appeal and Grievance Department Policies and Procedures. </li>
<li>Assists Appeals Coordinator, Clinical Pharmacist and Compliance with pharmacy benefit grievances as needed.</li>
<li>Handles calls and correspondence after hours (when scheduled) regarding pharmacy issues from providers and members. </li>
<li>Pharmacy Technicians are responsible for reporting any changes in licensure status (e.g., application declined/denied; license revoked/suspended or lapsed; notification of an investigation by licensing board; becoming subject to disciplinary action by a licensing board) to their direct supervisor throughout their term of employment.</li>
</ol>
Equal Opportunity Employer
The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.
 
 
 8:00am - 5:00pm 40

Pharmacy Technician

<h3>Job Description</h3>
Job DescriptionDescription:
 
Purpose:
The Student Services Advisor is responsible for the overall functioning and performance of the Student Services Department providing day-to-day leadership and direction with respect to policies, practices, systems and community support. The Student Services Advisor oversees the Student Services department with respect to scheduling and work assignments, Title IX compliance, ADA coordination, student complaints, grievances, appeals and performing other duties as required. The Student Services Advisor contributes to the College’s success by providing input into the development of the campus’ strategic and operational plans, and by ensuring that the campus achieves its student engagement, retention, and completion goals in a student centric campus environment. Responsible for taking a leadership role in cultivating and creating Smith Chason College campus spirit and pride.
 
Qualifications:
<ul>
<li>Bachelor’s degree preferred. Acceptable experience includes at minimum, 2-3 years of administrative experience. Recommended competencies include:</li>
<li>Must have strong technical skills including all computer applications, internet research, database management, and analytical skills.</li>
<li>Ability to prioritize, multi-task, perform well under pressure, meet deadlines, and work flexible schedule. </li>
<li>Ability to communicate with high level industry supervisors and management teams. </li>
<li>Strong ability to work independently as well as collaboratively with other team members. </li>
<li>Ability to engage in critical thought and analyze all types of quantitative and qualitative data into reports and presentation for strategic planning and problem-solving.</li>
<li>Ability to provide support and ensure accountability for results.</li>
<li>Strong organizational skills.</li>
<li>Effective time management skills; ability to separate important issues and identify priorities.</li>
<li>Ability to track, monitor, assess and evaluate student progress and registry outcomes.</li>
<li>Possesses strong motivational skills, oral and written communication proficiency.</li>
<li>Provide excellent customer service to all members of the WCUI community.</li>
<li>Must have strong documentation skills.</li>
<li>Demonstrates integrity, credibility, confidentiality, and responsibility in all interactions.</li>
<li>Possesses high ethical standards and an honest, open, and consistent approach to working with peers, employees, employers and staff.</li>
<li>Individuals must be professional in all aspects of the position including appearance, demeanor, communication and attitude.</li>
</ul>
Reports to:
Campus Director/ Director of Education
 
Responsibilities:
<ul>
<li>Lead and represent the Department of Student Services, ensure safety of students, regulatory compliance, consistency of practice and excellent student/customer service </li>
<li>Manage the Department’s work with faculty and staff, colleagues, students and community partners to support, provide and/or facilitate activities that ensure that the campus achieves its student engagement, satisfaction, retention, and completion goals </li>
<li>Provide leadership, analysis and advisement in relation to policies, procedures, and operational plans regarding students and services for students, including risk management. </li>
<li>Monitor, manage and enforce Satisfactory Academic Progress and Attendance Policies </li>
<li>Provide a leadership role with Title IX compliance and is the campus Title IX Coordinator </li>
<li>Work with the ADA Compliance Coordinator to facilitate all communication for requests for accommodations, ensure approved accommodations are communicated and managed and support students with the grievance process </li>
<li>Ensure that the Department’s budget is planned, prepared and monitored </li>
<li>Address complaints and conducts investigations as directed by the Campus Director </li>
<li>Hire, orientate, and supervise the Student Advocate by performing such things as: direct, schedule, provide performance feedback, evaluate, suggest professional development and where necessary discipline direct reports. Manage the performance review process </li>
<li>Ensure that Student Services Department monitors students’ attendance and academic performance on a weekly basis, progress toward program completion, providing or recommending interventions as needed </li>
<li>Ensure the Student Services Department maintains appropriate documentation with regards to advising sessions including meeting overviews, progress notes, referrals, and follow-up activities. </li>
<li>Ensure that the Student Services Department follows all regulatory bodies </li>
<li>Lead in the developing and conducting of student events including but not limited to orientation, community outreach, graduation and student appreciation </li>
<li>Maintain knowledge of Smith Chason College programs, campus resources, information systems, and policies and procedures </li>
<li>Additional job-related duties as required and assigned</li>
</ul>
 
PHYSICAL REQUIREMENTS/ WORKING CONDITIONS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
<ul>
<li>Must be able to remain in a stationary position for prolonged periods of time</li>
<li>Can independently move objects up to 25 lbs.</li>
<li>Sufficient hand, arm, and finger dexterity to operate a computer keyboard, other office machinery, and perform repetitive motions</li>
<li>Must have sufficient hearing and speaking ability to communicate in person or on the phone/computer with others</li>
<li>Must be able to occasionally function in activities that include walking, bending, squatting, and reaching</li>
</ul>
 
CULTURE OF CARE
Culture of Care is our commitment to create a supportive environment in which every student can achieve their educational and career goals. Culture of Care encourages one-on-one relationships. Creating a culture that focuses on the student and their wellness. This includes understanding the student's complex lives. It is about creating a school where everyone feels welcomed by: 
· Creating a sense of community in all interactions and communications with students 
· Identifying problem areas and offering assistance 
· Opening up safe conversations for cooperative solutions 
· Holding students to standards and goals that will ultimately make them successful in their careers
 
Requirements:

28 grievance-and-appeals-coordinator Jobs