field_job_employment_type

field_job_occupational_field_parents_all

job_organization_name

city

state

Manager Grievance &amp; Appeals (Provider Services) CalOptima CalOptima Health is seeking a highly motivated an experienced Manager, Grievance &amp; Appeals (Provider Services) to join our team. The Manager Grievance &amp; Appeals (Provider Services) will provide daily oversight and technical management for provider services, including provider disputes, provider grievances and provider appeal to ensure compliance with state, federal and accreditation standards applicable to CalOptima Health. The incumbent will work with CalOptima Health management staff and other affiliated health networks with a close interface to the program and process, including areas such as Utilization Management, Claims Administration, Delegation Oversight, Quality Improvement and health network relations. The incumbent will research complex claims problems, isolate root causes and partner with various entities for resolution. The incumbent will communicate with all levels of internal staff, regulatory agencies, health networks, providers, vendors, community-based organizations and medical groups. Position Information: 
<ul>
<li>Department: GA - Provider Disputes </li>
<li>Salary Grade: 315 - $109,892 - $175,827 ($52.83 - $84.5322) </li>
<li>Work Arrangement: Partial Telework **This position is eligible for telework in California.** </li>
</ul>
 Duties &amp; Responsibilities: 
<ul>
<li>50% - Program Oversight
<ul>
<li>Identifies and analyzes trends, collaborates with the Director to provide trends and makes recommendations for improvement.</li>
<li>Stays current on the local, state and federal health care environment, identifying issues that may impact CalOptima Health's programs as they relate to claims, provider disputes, grievances and provider appeals.</li>
<li>Develops, implements, maintains and reviews the adequacy of the CalOptima Health provider grievance systems, reporting, policies and functions to achieve stated goals, including, but not limited to, complaint resolution and timely responsiveness for all lines of business, to ensure compliance with all relevant regulatory requirements pertaining to provider disputes.</li>
<li>Works with the Audit and Oversight department and key departments to ensure internal departments and external partners (e.g., health networks and delegates) are up to date with regulatory, departmental and organizational changes impacting the grievance and appeals processes.</li>
<li>Ensures timely and effective data collection, summarization, integration and reporting, including, but not limited to, productivity, status and trend reports for specific committees such as the Quality Improvement Committee, Grievance and Appeals Committee, Quality Assurance Committee of the Board of Directors and other ad hoc reporting as required.</li>
<li>Serves as CalOptima Health's primary point of contact and subject matter expert related to provider services (disputes, grievances and appeals).</li>
<li>Participates in Department of Managed Healthcare (DMHC), Department of Health Care Services (DHCS) and Centers for Medicare and Medicaid (CMS) audits related to area of responsibility for all CalOptima Health programs. </li>
</ul>
</li>
<li>45% - Leadership
<ul>
<li>Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department.</li>
<li>Manages, hires, mentors and develops department staff.</li>
<li>Oversees the development and maintenance of internal policies and procedures and desktops to ensure compliance with all state and federal regulations for multiple lines of business.</li>
<li>Manages and makes recommendations on the development and maintenance of an effective dispute, appeals and grievance process and systems consistent with CalOptima Health policies and stated goals, including, but not limited to mechanisms to monitor provider disputes, grievances and appeals involving Legal, DMHC, DHCS, Independent Medical Review, Medi-Cal State Hearings, Office of Administrative Hearings and Appeals, CMS and external review agencies for CMS.</li>
<li>Partners with the management to ensure appropriate training and auditing tools are developed and maintained for the department. </li>
</ul>
</li>
<li>5% - Other
<ul>
<li>Completes other projects and duties as assigned. </li>
</ul>
</li>
</ul>
 Minimum Qualifications: 
<ul>
<li>Bachelor's degree in business administration, nursing, healthcare administration or related field PLUS 3 years of health care management experience in a related area of responsibility (provider disputes and appeals, claims administration, appeals and grievances) 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>3 years of leadership experience required. </li>
<li>Experience in health maintenance organization, Medi-Cal/Medicaid, Medicare Advantage, Medicare Part D, Special Needs Plans, Medicare-Medicaid Plans and/or the Program of All-Inclusive Care for the Elderly required.</li>
</ul>
 Preferred Qualifications: 
<ul>
<li>Experience with process improvement implementation.</li>
</ul>
 Required Licensure / Certifications: 
<ul>
<li>N/A</li>
</ul>
 Knowledge &amp; Abilities: 
<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>
 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>
 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>
 About CalOptima Health: CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! About our Benefits &amp; Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the <a href="https://apptrkr.com/get_redirect.php?id=6357344&amp;targetURL=https://alliantbenefits.cld.bz/24caloptimacabenguide" target="_blank">2024 CalOptima Health Benefits Guide</a> and our <a href="https://apptrkr.com/get_redirect.php?id=6357344&amp;targetURL=https://alliantbenefits.cld.bz/25caloptimacabenguide" target="_blank">2025 CalOptima Health Benefits Guide</a> regarding our comprehensive benefits and wellness package. IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is July 16, 2025 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet. Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application. 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/6357344" target="_blank">https://jobs.caloptima.org/jobs/manager-grievance-appeals-provider-services-505-city-parkway-west-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-cf7b2c04c4b10840a8654602344b5194

Manager Grievance & Appeals (Provider Services)

Civil Rights Investigator and Complaint Resolution Officer

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 and Appeals Coordinator CalOptima $28-31/HR Orange CA - 92868 Duties &amp; Responsibilities: 95% - Program Support Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department. Maintains adequate information in CalOptima Health’s systems; ensures data collection, summarization, integration and reporting which includes case creation and management and events/activity tracking. Gathers pertinent information regarding the grievances and appeals received, including member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal or supplemental information required to evaluate grievances and appeals within regulatory requirements. Coordinates and participates in case discussions with operational experts to result in a final case disposition as needed. Evaluates case details, proposes recommendations or makes decisions as applicable and ensures the organization’s decision is implemented according to the Grievance and Appeals policies and case resolution. Develops resolution letters and correspondence to members and providers. Communicates with internal and external customers to ensure timely review and resolution of grievances or appeals. Contacts appropriate parties to request and obtain missing information and supporting documentation or provides education. Reads and interprets provider contracts, Division of Financial Responsibility (DOFR), policies, procedures and instructions. Responds to routine provider inquiries via phone, assisting with provider appeals resolution inquiries. Assists with the health networks’ compliance process. Identifies trends and root causes of issues, proposes solutions or escalates ongoing issues to management. Meets performance measurement goals for Grievance and Appeals Resolution Services. 5% - Completes other projects and duties as assigned. Minimum Qualifications: High school diploma or equivalent PLUS 1 year of experience with Provider Dispute Resolution (PDR) in Medicare and Medi-Cal in professional, institutional, outpatient, ancillary, coordination of benefits and government cases required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying. 1 year of experience with Medicare or Medi-Cal provider appeals and denials process required. 1 year of experience in any of the following areas: Grievances and Appeals, Claims Administration, Regulatory Compliance, Customer Service or related field required. Preferred Qualifications: Associate degree in business, health care administration or related field. Experience in health care practice standards, for both government and commercial plans. Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese). Required Licensure / Certifications: N/A Knowledge &amp; Abilities: Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. Work independently and exercise sound judgment. Communicate clearly and concisely, both orally and in writing. Work a flexible schedule; available to participate in evening and weekend events. Organize, be analytical, problem-solve and possess project management skills. Work in a fast-paced environment and in an efficient manner. Manage multiple projects and identify opportunities for internal and external collaboration. Motivate and lead multi-program teams and external committees/coalitions. Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. &nbsp;
Company DescriptionIT Mantra, LLC. is a Certified Woman / Minority (WBE/MBE) owned company founded in 2003 and based in Massachusetts. We provide a comprehensive range of IT and Professional Staffing and Workforce Solutions that include contract, contract to hire and direct hire placement services as well Employer of Record (EOR) services nationally and specialize in the placement of women and diverse personnel. 
<h3>Company Description</h3>
IT Mantra, LLC. is a Certified Woman / Minority (WBE/MBE) owned company founded in 2003 and based in Massachusetts. We provide a comprehensive range of IT and Professional Staffing and Workforce Solutions that include contract, contract to hire and direct hire placement services as well Employer of Record (EOR) services nationally and specialize in the placement of women and diverse personnel.

Grievance and Appeals Coordinator

<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
Position Summary:
DaMar Staffing Solutions is seeking a compassionate and highly skilled LTSS RN Coordinator– Clinicians to support individuals transitioning from inpatient settings such as emergency departments, hospitals, skilled nursing facilities, or nursing homes. This role is critical in facilitating person-centered care planning and ensuring continuity of care during transitions. The LTSS RN Coordinator serves as a clinical liaison and advocate for patients, working closely with LTSS Coordinators, contracted providers, and interdisciplinary teams to promote safe, efficient, and high-quality care.
This position focuses on building trusting relationships with members and their families, preventing unnecessary readmissions, providing geriatric support, and optimizing the use of healthcare resources.
Key Responsibilities:
<ul>
<li>Conduct in-person, virtual, and/or telephonic outreach to patients, providers, and stakeholders involved in transitions of care.</li>
<li>Serve as a patient advocate to resolve barriers and ensure access to needed services and resources.</li>
<li>Collaborate with LTSS service coordinators and clinical teams to identify risks and ensure alignment with the Person-Centered Service Plan (PCSP).</li>
<li>Engage hospital staff (e.g., physicians, case managers, discharge planners) to support timely, safe discharges and effective post-acute care planning.</li>
<li>Participate in case reviews, discharge planning meetings, and facilitate communication across the care continuum.</li>
<li>Assist with reviewing medical records and utilization data to ensure appropriate care and identify discharge barriers.</li>
<li>Provide education and support to patients and families regarding care plans, discharge instructions, medications, follow-up care, and available community resources.</li>
<li>Complete structured clinical assessments to determine post-discharge needs including medical equipment, follow-up appointments, home health services, and caregiver support.</li>
<li>Ensure documentation and tracking of transition interventions comply with internal protocols and external regulatory requirements (CMS, NCQA, state-specific).</li>
<li>Report critical incidents to appropriate regulatory or state agencies when needed.</li>
<li>Participate in member grievance or appeals processes, audits, and hearings as necessary.</li>
<li>Offer mentorship and training to new staff as needed and support quality improvement efforts.</li>
</ul>
Minimum Qualifications:
<ul>
<li>Active Registered Nurse (RN) license in the state of Indiana and in good standing.</li>
<li>At least 2 years of clinical experience in transitional care, emergency department, discharge planning, or home health settings.</li>
</ul>
Preferred Qualifications:
<ul>
<li>Strong knowledge of Medicaid, NCQA standards, and transitions of care protocols.</li>
<li>Familiarity with inpatient care management and utilization review processes.</li>
<li>Reliable transportation and willingness to travel up to 80% of the time within a designated regional territory (Monday–Friday, 8 AM–5 PM).</li>
<li>Company will hire RNs working in the following counties: Marion, Lake, Union, Vanderburgh, Allen, Floyd</li>
<li>Strong communication skills and ability to engage with diverse stakeholders, including patients, families, and healthcare teams.</li>
<li>Ability to identify cost-effective care strategies that support high-quality outcomes.</li>
<li>Proficient with documentation and clinical recordkeeping systems.</li>
<li>Independent problem-solving skills and a proactive, patient-centered approach.</li>
<li>Starting Salary $75,000 to $90,000 based on year of experience, mileage reimbursement; competitive health insurance and benefits.</li>
</ul>
Company DescriptionDaMar Staffing Solutions of Indianapolis (“DaMar”) is a premier boutique recruitment firm. The DaMar model offers on demand solutions at an affordable price. DaMar Staffing Solutions is the place for professional level staffing for all industries . 
<h3>Company Description</h3>
DaMar Staffing Solutions of Indianapolis (“DaMar”) is a premier boutique recruitment firm. The DaMar model offers on demand solutions at an affordable price. DaMar Staffing Solutions is the place for professional level staffing for all industries .

LTSS RN Coordinator

<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
Job Title: Grievance Complaint Manager
Location: Glencoe MD 21152
Pay: $28.00- $30.00 per hour
Scheduled Pay: Bi-Weekly Job Type: Full Time Benefits: Health, Dental, Vision, Life Insurance, and Short term disability after 90 days
Ready to apply or have questions?
Contact- Ashley Kruger Call/Text- 586-710-7947
 Grievance Complaint Manager Duties and Responsibilities:
<ul>
<li>Administrative data collection and entry.</li>
<li>This role is customer facing with internal and external customers.</li>
<li>Communication methods consists of physical mailings, phone calls, emails, and conference calls.</li>
<li>Data entry into excel spreadsheet.</li>
<li>Contact information collection and documentation.</li>
<li>Document information gathered.</li>
<li>Ability to triage complex customer inquiries, understand the appropriate parties to resolve, and minimize the number of hand-offs for the customer.</li>
<li>Ensures compliance with all policies and procedures.</li>
<li>Routing the calls to appropriate departments for further assistance. In the event multiple departments are involved, take on the task to resolve then call back the customer.</li>
<li>Make Outbound calls to various customers to verify if field action notifications have been received.</li>
<li>Able to navigate through large medical facilities to identify correct party to acknowledge corrective action notices.</li>
<li>Maintain detail records of outbound calls such as representative names, titles, disposition of any products.</li>
<li>Raise any escalated concerns to the next level of management.</li>
</ul>
Ready to apply or have questions?
Contact- Ashley Kruger Call/Text- 586-710-7947
Grievance Complaint Manager Requirements:
<ul>
<li>HS Diploma/GED required / Associates Degree preferred</li>
<li>Minimum 2 years experience in a management position resolving complaints / customer concerns</li>
<li>Working knowledge of 21 CFR820, ISO 13485, and other international standards preferred</li>
<li>Proficiency in Microsoft Office, specifically Word and Excel</li>
<li>Strong Verbal Communication skills</li>
</ul>
Ready to apply or have questions?
Contact- Ashley Kruger Call/Text- 586-710-7947
Keywords: Customer Complaint Resolution Manager, Customer Satisfaction Manager, Client Relations Manager, Customer Care Manager, Service Quality Manager, Grievance and Appeals Manager, Patient Relations Manager, Member Complaints Manager, Quality of Care Coordinator, Escalation Manager, Client Support Manager, Technical Support Escalation Lead, Issue Management Specialist

Customer Resolution Manager

<h3>Job Description</h3>
Site: Mass General Brigham Health Plan Holding Company, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. The ideal candidate for this role will have Medicare Advantage appeals experience. Part of this role is building cases, gathering information to support an appeal, and making cases from beginning to end. The ideal candidate has experience building the IRE case file. Job Summary While a remote role, this team meets every quarter at the office at Assembly Row in Somerville and attendance is highly encouraged. This role would also require on-call coverage on the weekends/holidays (currently every other weekend). The Clinical Appeals and Grievance Coordinator (RN) is an integral part of our Appeals and Grievance review process. Under the direction of the Director of Appeals and Grievances, this clinician will ensure clinical/pharmacy appeal cases reviews meet contractual, regulatory and business goals. As part of the Clinical Appeal process, the Clinical Appeals and Grievance Coordinator (RN) collaborates with members of the Appeal and Grievance team, pharmacy team, and medical director teams to resolve all types of clinical issues across the clinical/pharmacy appeal landscape. Essential Functions Clinical Appeals Review 
<ul>
<li> In conjunction with other appeal team members, ensures that clinical/pharmacy appeals and grievances are resolved timely to meet regulatory timeframes</li>
<li> Directly interact with providers and their staff to obtain additional clinical information as well as with members or their advocates to understand the full intent of the appeal or clinical grievance.</li>
<li> Review clinical/pharmacy appeal cases and provide recommendations to the medical director team based on analysis of the clinical material</li>
<li> Interact closely with pharmacy staff on pharmacy related reviews in preparation for physician review if needed</li>
<li> Identify cases that may require specialty review and expedite submission of cases to our contracted vendor (s) for this purpose</li>
<li> Analyze and complete written summaries on clinical cases.</li>
<li> Maintain compliance with all required turnaround times</li>
<li> Maintain compliance with all regulatory and NCQA requirements with regards to this important work</li>
<li> Other duties as assigned with or without accommodation. </li>
</ul>
Qualifications Education: 
<ul>
<li>Bachelor’s Degree in Healthcare Administration, Nursing, or related field of study required </li>
</ul>
Licenses and Certifications 
<ul>
<li>Massachusetts Registered Nurse (RN) license required </li>
</ul>
Work Experience 
<ul>
<li>At least 3-5 years of experience in clinical appeals, grievances, utilization review, or related healthcare services required, with a strong preference for health plan experience</li>
<li>At least 2-3 years of clinical experience required </li>
</ul>
Preferred 
<ul>
<li>At least 3-5 years of Medicare Advantage appeals</li>
<li>At least 5 years of experience working with members, providers, and internal staff on complex and sensitive requests for clinical services is highly preferred</li>
<li>At least 5 years of experience working in multiple data systems is highly preferred</li>
<li>Experience with multiple product lines, including Commercial, Exchange, Medicaid, and Medicare Advantage highly preferred</li>
<li>Familiarity with InterQual Criteria</li>
<li>Knowledge of Medicare national and local coverage determinations </li>
</ul>
Skills/Competencies 
<ul>
<li>Demonstrate Mass General Brigham Health Plan’s core brand principles of always listening, challenging conventions, and providing value.</li>
<li>Bring fresh ideas forward by listening to and collaborating with employees and the people we serve.</li>
<li>Strong aptitude for technology-based solutions.</li>
<li>Ability to inject energy, when and where it’s needed.</li>
<li>Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback.</li>
<li>Be accountable for delivering high-quality work. Act with a clear sense of ownership.</li>
<li>Bring fresh ideas forward by actively listening to and working with employees and the people we serve.</li>
<li>Excellent critical thinking, analytical, and organizational skills</li>
<li>Proficient in Microsoft Office products</li>
<li>Proficient in internet research</li>
<li>Ability to work well both independently and in a team</li>
<li>Excellent oral and written communication skills</li>
<li>Meticulous attention to detail</li>
<li>Ability to influence others and persevere in situations</li>
<li>Ability to initiate administrative activities as necessary and institute quality control procedures.</li>
<li>Ability to manage multiple cases, meet deadlines, and adjust to changes in company policies, procedures, and priorities.</li>
<li>Ability to read, analyze and interpret clinical research, general business periodicals, professional journals, government regulations and legal documents.</li>
<li>Ability to effectively present information and respond to inquiries from employees, senior management, and regulatory agencies </li>
</ul>
Action 
<ul>
<li>Provides recommendations on all clinical/pharmacy appeal cases for medical director review</li>
<li>Provider outreach as necessary to obtain additional clinical information</li>
<li>Work independently on cases while meeting obligatory turnaround times</li>
<li>Submission of appeal cases external vendors as required</li>
<li>Drafting appeal and grievance resolution correspondence prior to final review </li>
</ul>
Organizational Relationships/Scope 
<ul>
<li>Reports directly to the Director, Appeals and Grievances and ensures the department goals set forth by the Director and Chief Medical Officer are met.</li>
<li>Work collaboratively with others within Quality and Clinical and across all departments </li>
</ul>
Working Conditions Additional Job Details (if applicable) 
<ul>
<li>While a remote role, this team meets every quarter at the office at Assembly Row in Somerville and attendance is highly encouraged.</li>
<li>This role requires on-call coverage on the weekends/holidays (currently every other weekend) </li>
</ul>
Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) EEO Statement Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.

19 grievance-and-appeals-coordinator Jobs