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Program/Policy Analyst Sr (Medi-Cal Compliance) CalOptima CalOptima Health is seeking a highly motivated Program/Policy Analyst Sr (Medi-Cal Compliance) to join our team. The Program/Policy Analyst Sr (Medi-Cal Compliance) will coordinate and maintain CalOptima Health's relationship with regulatory agencies and ensure CalOptima Health and its First Tier, Downstream and Related Entities (FDRs) comply with all appropriate standards, regulations, contractual provisions, federal waivers and laws. Specifically, the incumbent works to enhance and strengthen CalOptima Health's policy infrastructure, platform and strategies at the state level, including contract compliance, statutory and regulatory obligations with the Department of Health Care Services (DHCS). The incumbent requires the ability to complete a variety of independent detailed analyses, including the development, review and response to corrective action plans. The incumbent will be responsible implementing Corrective Action Plans (CAPs), supporting regulatory audits, validating regulatory guidance and developing regulatory communications for CalOptima Health stakeholders. The incumbent will interact with CalOptima Health's executives and department management, FDR's management, legal counsel and state and federal regulatory agencies. The incumbent will also support other key CalOptima Health staff on related projects. Position Information: 
<ul>
<li>Department: OOC - MediCal Regulatory Affairs &amp; Compliance </li>
<li>Salary Grade: 311 - $77,863 - $124,581 ($37.43 - $59.8947) </li>
<li>Work Arrangement: Full Telework **This position is eligible for telework in California.** </li>
</ul>
 Duties &amp; Responsibilities: 
<ul>
<li>85% - Program Support
<ul>
<li>Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Works with all of CalOptima Health's departments in response to inquiries, problem-solving and promoting CalOptima Health's mission and message.</li>
<li>Assists in the management of CalOptima Health's daily relationship with the DHCS for CalOptima Health's Medi-Cal program.</li>
<li>Maintains open lines of communication to ensure the ongoing trust and confidence of regulators in the program and management.</li>
<li>Researches, analyzes and makes recommendations regarding the policy implications of major initiatives for CalOptima Health's Medi-Cal program, e.g., integration of new benefits and populations.</li>
<li>Works with business areas at all levels of leadership to validate regulatory communications from regulators impacting CalOptima Health's Medi-Cal program.</li>
<li>Supports process improvements for the Office of Compliance department.</li>
<li>Serves as a Medi-Cal regulatory subject matter expert and lead for CalOptima Health's compliance issues and investigations.</li>
<li>Supports management in the readiness, coordination, oversight and remediation of regulatory audits, including but not limited to validating business area submissions, additional audit requests and written daily reports.</li>
<li>Researches and responds in a professional manner to questions pertaining to the Medi-Cal program.</li>
<li>Works with the director and manager with interactions and responses to regulatory representatives on compliance-related issues as needed.</li>
<li>Reviews and retains working knowledge of Medi-Cal policies and procedures related to assigned programs and projects.</li>
<li>Assists in the creation of communications and strategic alliances with regulators.</li>
<li>Researches and keeps current on the local, state and federal health care environment and health policy, identifying issues that may impact CalOptima Health's Medi-Cal program.</li>
<li>Coordinates the maintenance of public program benefit updates for accurate and consistent application by CalOptima Health and its provider community.</li>
<li>Participates and represents CalOptima Health in meetings and calls with regulators and associations and summarizes key points and impact to CalOptima Health's Medi-Cal program as needed. </li>
<li>10% - Administrative Support</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>Initiates, facilitates and promotes activities to foster compliance awareness and encourages the reporting of compliance issues within the organization and related entities. </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 health services administration, public health, public policy or a related field PLUS 4 years of experience in government, public or government affairs role in health care compliance or health plan requirements 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>
 Preferred Qualifications: 
<ul>
<li>Master's degree. </li>
<li>Experience working with regulatory agencies in California. </li>
<li>Experience with Medi-Cal regulatory requirements and/or compliance in the areas of Customer Service, Grievance &amp; Appeals, Quality Improvement, Case Management, Claims Administration and/or Utilization Management. </li>
<li>Certification in Healthcare Compliance (CHC) or other compliance related certifications such as Certified Compliance and Ethics Professional.</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, 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=6296744&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 June 25, 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/6296744" target="_blank">https://jobs.caloptima.org/jobs/program-policy-analyst-sr-medi-cal-compliance-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-c10c0223e159b943b7243c210753f920

Program/Policy Analyst Sr (Medi-Cal Compliance)

<h3>Job Description</h3>
Job DescriptionDescription:
Verda Health Plan of Texas has a contract with the Center of Medicaid and Medicare Services (CMS) and a state license with the Texas Department of Insurance for a Medicare Advantage Prescription Drug (MAPD) plan. We are committed to the idea that healthcare should be easily and equitably accessed by all. Our mission is to ensure that underserved communities have access to health and wellness services, and receive the support needed to live a healthy life that is free of worry and full of joy. We are looking for a Grievance &amp; Appeal Representative to join our growing company with many internal opportunities.
 
Are you ready to join a company that is changing the face of health care across the nation? Verda Healthcare, Inc is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity. Align your career goals with Verda Healthcare, Inc and we will support you all the way.
 
Position Overview
The Grievance &amp; Appeal Representative responds to all types of written/verbal grievances, complaints, appeals and disputes submitted by members and providers: review, analyze, research, respond and resolve all inquiries, in accordance with guidelines established by CMS and other regulatory agencies, where applicable, as well as internal policies. Will work with Clinical department regarding appeals related to Clinical policy. Work as an effective interface between internal and external customers. Maintain good member and provider relations relationship. 
 
****This position is part of Call Center. This position reports to the Manager of Enrollment. 
 
Job Responsibilities
· Review and evaluate appeal and grievance request to identify and classify member and provider appeals, hand-off to appropriate department for provider and clinical appeals; process member and provider complaints as appropriate to meet the CMS, State and Accreditation requirements. 
· Determine eligibility, benefits, and prior activity related to claims, payment or service in question.
· Review research performed by operational areas to ensure the appropriate resolution to the appeal/grievance has been achieved, review contracts, member materials, medical payment policies, and provider education documents in researching and deciding the outcome of appeals.
· Accountable for appropriate review and determination in compliance with state and federal regulations.
· Conduct thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities.
· Perform comprehensive research related to the facts and circumstances of a member complaint, to include appropriate classification as a grievance, appeal, or both, in accordance wit regulatory requirements.
· Research appeal files for completeness and accuracy and investigate deficiencies. Consult with internal areas as required (such as the Legal Department) to clarify legal ramifications around complex appeals.
· Provide written acknowledgement of member and provider correspondence, prepare written responses to all member and provider correspondence that appropriately address each complaint’s issues and are structurally accurate. 
· Follow-up with departments responsible to ensure compliance.
· Responsible for making verbal contact with the member or authorized representative during the research process to further clarify, as needed, for the member’s complaint. 
· Ensure documentation requirements are met create and document service requests to track and resolve issues; document final resolutions along with all required data to facilitate accurate reporting, tracking and trending. 
· Provide all follow up documentation of outcome to practitioners, providers, and members. 
· Responsible for the timely, complete, accurate documentation of the appeal and/or grievance both electronically, and hard copy, and for timely and accurate written documentation to the member and/or provider advising of the resolution of the appeal and/or grievance. 
· Responsible for ensuring appeals case files are accurately prepared and submitted to the IRE within 24 hours of the decision to uphold the initial denial for expediated appeals, and not later than 30 calendar days after the receipt of a standard pre-service appeal and 60 days after the receipt of a claim appeal. 
· Enter and maintain critical data and records in support of Verda Health Plan business requirements, regulatory obligations timeframes, monitor daily and weekly pending reports and personal worklists, ensuring internal and regulatory timeframes are met. 
· Enter and maintain critical data and records in support of business requirements, regulatory timeframes, and NCQA standards, into the appropriate systems. 
· Track and trend outcomes and analyze data to provide reporting as required for UM, QA, etc. and to identify provider education opportunities. 
· Responsible for monitoring the effectuation of all resolution/outcomes resulting from the appeals, Administrative Law Judge, and Medicare Appeals Council processes. 
· Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution, quality improvement, network contracting, policies and procedures, administrative costs, cost saving opportunities, best practices, and performance issues. 
· Serve as liaison with medical groups and network physicians to ensure timely resolution of cases; collaborate and partner with internal departments for resolution and education, work with physicians, hospitals and internal staff to gather information needed to resolve complex claim issues. 
· Perform other tasks, projects, etc. as needed or directed
Requirements:
Minimum Qualifications
· Associate’s degree required, Bachelor’s preferred. 
· In lieu of degree, equivalent education and/or experience may be considered. 
· 3+ years of related, professional work experience required.
· 2 years’ experience in Medicare Managed Care preferred. 
· Experience in a managed care/compliance environment preferred. 
· Knowledge of medical terminology, provider reimbursement, medical coding, coordination of benefits and all types of medical claims required. 
· Solid understanding of member and provider rights and responsibilities, particularly with appeals and grievance required.
· Familiarity with managed care, state and federal regulations is required.
· Prior auditing experience preferred. 
· Customer Service experience preferred.
· Knowledgeable in medical terminology and have prior ACD experience.
· Demonstrates good judgment, organization and prioritization skills and time management skills.
· Proven leadership with staff, projects, and management.
· Strategic thinking abilities and analytical skills
· Ability to clearly present written information and findings, concisely communicate concepts and make executive-level presentations.
 
Professional Competencies
· Integrity and Trust
· Customer Focus
· Functional/Technical Skills
· Written/Oral Communications
· Critical/Analytical Thinker
 
Verda cares deeply about the future, growth, and well-being of its employees. Join our team today!
 
Job Type: Full-time
Benefits:
<ul>
<li>401(k)</li>
<li>Paid time off (vacation, holiday, sick leave)</li>
<li>Health insurance </li>
<li>Dental Insurance</li>
<li>Vision insurance </li>
<li>Life insurance</li>
</ul>
Schedule:
<ul>
<li>Full-time onsite (100% in-office)</li>
<li>Hours of operations: 9am – 6pm</li>
<li>Standard business hours Monday to Friday/weekends as needed</li>
<li>Occasional travel may be required for meetings and training sessions.</li>
</ul>
Ability to commute/relocate:
<ul>
<li>Reliably commute or planning to relocate before starting work (Required)</li>
</ul>
PHYSICAL DEMANDS
Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds.
*Other duties may be assigned in support of departmental goals.

Grievance & Appeal Representative

<h3>Job Description</h3>
Job DescriptionOur client in Westerville, Ohio is seeking an AR Clerk for a contract opportunity. The position is full time onsite for the first 90 days, then can go to 2 days a week onsite which will be chosen by the manager of the group. Essential Activities and Tasks Billing and Collections - 90% 
<ul>
<li>Maintain, obtain, retain and apply knowledge regarding the specific billing requirements for Medicare, Medicaid, all other third party commercial insurance funding sources; other federal, state, county, local programs; and, direct billing and collections of amounts due directly from the patients/consumers.</li>
<li>Prepare and transmit all claims electronically using specified software, as well as insurance carrier and other governmental agency internet portals within established monthly billing performance timeframe and by prescribed due dates. This includes billing primary and secondary third party agencies.</li>
<li>Review and balance all assigned ancillary service files provided by various vendors by the prescribed dates for the month end close billing cycle to ensure all ancillary services are captured in billing files to enable accurate claims.</li>
<li>Ensure that all required documents are scanned into the electronic medical record for the date required prior to claims release. Adhere to supervisory internal control review requirements before release of claims.</li>
<li>Validate payer data for patients that intake personnel identified to ensure the proper third party payer, as indicated by the payer guide, and make corrections when necessary.</li>
<li>Validate that required precertification, preauthorization, authorization and re-authorizations were obtained in order to communicate with site personnel to take appropriate action to minimize uncollectible accounts receivable.</li>
<li>Identify and escalate site or payer related issues to supervisor/manager in a timely manner.</li>
<li>Monitor status of collections and appropriate cash receipt application to correct patient account balances.</li>
<li>Identify denied claims on a daily basis. Research, correct and resubmit claims on a daily basis via prescribed software, third party and government agency internet portals, or mail if only option. Escalate any continuing or complicated matters to supervisor/manager for additional attention and potential consultant advisory.</li>
<li>Communicate with third party and governmental agencies to facilitate successful correction and payment of claims when necessary. Communicate with site representatives when necessary to assist in resolution of denied claims.</li>
<li>Assemble information to enable responses to additional development requests to support clinical necessity of claims, and for cases where grievance or appeal is appropriate. Communicate with site and corporate representatives as necessary to facilitate responses to third party agencies. Track and report status.</li>
<li>Prepare, review and release private pay invoice statements, using specified software, within established monthly billing performance timeframe and by prescribed due dates. Invoice statements should be completely accurate with minimal and infrequent errors subsequently discovered. Adhere to supervisory internal control review requirements before release of claims. Established supporting documents or special statement inserts must be included in the mailing.</li>
<li>Field incoming patient, consumer, and/or appropriate family member or guardian calls or emails in a professional and responsive manner. Perform appropriate account research and activity verification. Develop thoughtful and accurate response and send to inquirer. Escalate more complex matters to supervisor/manager when appropriate.</li>
<li>Make collection calls at prescribed intervals. Prepare and send collection letters at prescribed intervals. Develop payment plan options when appropriate and within prescribed guidelines. Refer certain accounts to attorneys or collection agency upon supervisor/manager approval. </li>
<li>Review accounts receivable aging reports to identify outstanding balances and take appropriated action to research and resolve outstanding balances. Goals for overall days in accounts receivable, targeted outstanding balances needing resolution and expecting timing will be established on a monthly basis by supervisor/manager.</li>
</ul>
 Financial Management and Support - 10% 
<ul>
<li>Prepare and provide for review and approval all accounts receivable write-off and other types of revenue or receivable balance adjustments as needed with all required supporting documentation. </li>
<li>Identify and notify supervisor/manager of other potential issues through use of various reports that may indicate the need to make revenue, receivable, payer, or rate corrections to ensure that revenue and receivables are recorded accurately and timely.</li>
<li>Identify and offer suggestions pertaining to process improvements.</li>
<li>Communicate collaboratively with other account receivable coordinators to resolve any common patient/consumer receivable matters.</li>
<li>Successfully transition through payer education requirements by pre-determined deadlines, including all payer facility contracting relationships, payer rules and regulations and payer appeals and grievances process.</li>
<li>Participate in recurring team meetings and trainings. Assist and/or be present for site personnel trainings.</li>
<li>Prepares other special reports and performs other tasks or projects as requested and/or required.</li>
</ul>
 All other duties as assigned. Qualifications 
<ul>
<li>High school diploma or equivalent required.</li>
<li>Associate degree in a related field preferred, accounting coursework or concentration desired.</li>
<li>Three years experience performing billing operations preferred.</li>
<li>Experience in home health, hospice, or long-term care healthcare accounting required.</li>
<li>Experience with accounts receivables analytics preferred.</li>
<li>Proficiency with Windows, Microsoft Office (Word, Excel, PowerPoint), and the internet required.</li>
<li>Must be able to read, write, speak, and understand the English language.</li>
</ul>
 Working Conditions and Special Requirements 
<ul>
<li>Sitting - Up to 8 hours/day</li>
<li>Standing - Up to 2 hours/day</li>
<li>Walking - Up to 2 hours/day</li>
<li>Lifting, transferring, pushing or pulling equipment/supplies - Up to 25 pounds</li>
<li>Driving - Up to 6 hours/day</li>
<li>Work weekends, evenings, and holidays - As needed for coverage</li>
<li>Risk Category for Exposure to Bloodborne Diseases - III</li>
</ul>
 Reference: 1029949 Worried that you don’t meet every single requirement listed in the job ad? Studies have shown that individuals from marginalized groups are less likely to apply to jobs unless they meet every single qualification. Hive + Co. is dedicated to building a diverse, inclusive and representative workplace, so if you’re excited about this role, but worried that you don’t meet every requirement, we encourage you to apply anyways. We’d love to get to know you.

AR Clerk | 1029949

<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>
Job Description
 
Under the supervision of the Call Center Manager, the Call Center Representative shall ensure that all incoming DWIHN Call Center phone calls are answered and assessed for severity in order to triage the call and provide the most appropriate services. 
PRINCIPAL DUTIES AND RESPONSIBILITIES:
<ul>
<li>Answers all phone calls using the approved telephone answering script on one of three shifts for the DWIHN 24-hour Call Center. </li>
<li>Assesses the call for crisis. </li>
<li>Conducts warm transfers for any caller in crisis to a crisis counselor. </li>
<li>Identifies and transfers callers to appropriate community resources.</li>
<li>Responds to requests from Emergency Departments.</li>
<li>Responds to requests from Emergency Departments for children’s mobile crisis teams and dispatches the appropriate team. </li>
<li>Documents all incoming telephone calls. </li>
<li>Collects demographic information on all calls. </li>
<li>Conducts warm transfers for any caller who needs a clinical assessment/screen to a Call Center Clinician. </li>
<li>Ensures all aspects of the Enrollment/Re-Enrollment process are conducted. </li>
<li>Responds to inquiries regarding enrollment and eligibility. </li>
<li>Performs enrollment changes according to The Detroit-Wayne Integrated Health Network criteria and guidelines.</li>
<li>Complies with the default CRSP assignment protocol. Assesses the Detroit Wayne Integrated Health Network MH-WIN Database for eligibility determination, look-up, enrollment, and default CRSP assignment. </li>
<li>Verifies that a consumer is a resident of Wayne County. </li>
<li>Assigns consumers to a CRSP via the Preference or Random request system. </li>
<li>Documents all calls in MH_WIN. </li>
<li>Documents all ineligible or incomplete enrollments in the MH-WIN database. </li>
<li>Conducts monthly TDD/TTY tests. </li>
<li>Gathers information regarding complaints or grievances and completes the appropriate documentation. </li>
<li>Ensures that all aspects of the Consumer Complaint, Grievance, and Appeals Process are forwarded to Customer Services. </li>
<li>Provides consumers with accurate information as to the grievance, appeal and local dispute resolution process associated with their specific benefit plan. </li>
<li>Provides information regarding the complaint management systems of the public mental health systems and the specific benefit plans.</li>
<li>Ensures that all call logs and enrollment documentation are complete before the end of the work shift. </li>
<li>Documents all compliments and complaints. </li>
<li>Notifies a supervisor immediately of consumer complaints. </li>
<li>Performs follow up calls and customer satisfaction surveys.</li>
<li>Attends monthly staff meetings.</li>
<li>Attends required trainings.</li>
<li>Performs related duties as assigned.</li>
</ul>
KNOWLEDGE, SKILLS AND ABILITIES (KSA’s) 
<ul>
<li>Knowledge of DWIHN policies, procedures and operations.</li>
<li>Knowledge of the DWIHN provider network.</li>
<li>Knowledge of medical and behavioral health practices and terminology.</li>
<li>Knowledge of Customer Service practices and principals.</li>
</ul>
<ul>
<li>Knowledge of co-occurring and substance use treatment services. </li>
<li>Knowledge of priority population admittance. </li>
<li>Knowledge of State Disability Assistance (SDA).</li>
<li>Computer skills</li>
<li>Time management skills</li>
<li>Organizational skills</li>
<li>Critical thinking skills</li>
<li>Decision Making skills</li>
<li>Customer Service skills</li>
<li>Language skills</li>
<li>Listening skills</li>
<li>Teamwork skills</li>
<li>Ability to communicate orally.</li>
<li>Ability to communicate in writing.</li>
<li>Ability to work effectively with others.</li>
<li>Ability to work with an ethnically, linguistically, culturally, economically and socially diverse population.</li>
<li>Judgement/Reasoning ability.</li>
</ul>
Required Education:
<ul>
<li>A Bachelor’s Degree from a recognized college or university in a Human Service, Social Service, Public Health, Public Administration, Healthcare Administration, Health Management or a related field.</li>
</ul>
 
Required Experience:
<ul>
<li>Two (2) years of full-time paid experience working in a human service or social service field.</li>
</ul>
Working Conditions
Work is usually performed in a home/office setting. 
Contingent staff are allowed to work remotely with management approval. 
NOTE: The DWIHN Call Center is a 24/7 operation. Employees in the Call Center may be required to work one of three shifts (Days, Afternoons, Midnights) and weekends.

This description is not intended to be a complete statement of job content, rather to act as a general description of the essential functions performed. Management retains the discretion to add or change the position at any time. 

Please Note: DWIHN requires proof of being fully vaccinated for COVID-19 as a condition of employment. Medical or religious accommodations or other exemptions that may be required by law, will be approved when properly supported. Further information will be provided during the recruitment process. 
DWIHN is an Equal Opportunity Employer

Call Center Representative Contingent

<h3>Job Description</h3>
Job DescriptionAbout us:
Solis Health Plans is a new kind of Medicare Advantage Company. We provide solutions that are more transparent, connected, and effective for both our members and providers. Solis was born out of a desire to provide a more personal experience throughout all levels of the healthcare journey. Our team consists of expert individuals that take pride in delivering quality service. We believe in a culture that collaborates and supports one another, and where success is interlinked, and each employee is valued. Please check out our company website at <a href="http://www.solishealthplans.com" target="_blank">www.solishealthplans.com</a> to learn more about us!
 
Position is FULLY ON SITE Monday-Friday.
Location: 9250 NW 36th St, Miami, FL 33178.
 
Full benefits package offered on the first on the month following date of hire including: Medical, Dental, Vision, 401K plan with a 100% company match!
Our company has doubled size and we have experienced exponential growth in membership from 2,000 members to over 10,000 members!
Join our winning Solis Team! 
 
Position Summary:
 
Solis Health Plans is looking for a Member Services Representative primarily responsible for providing quality, professional service to all customers when calls are received through the Member Services Department via telephone, written or in-person in accordance with Plan guidelines.
 
Essential Duties and Responsibilities:
<ul>
<li>Handles telephone, written and in-person inquiries in a courteous, professional, thorough, and timely manner to assure member satisfaction.</li>
<li>Assists callers on inquiries regarding coverage decisions, grievances, appeals, benefit interpretation, eligibility verification, medical group/PCP, explanation of how the plan works and how to utilize services, assists with information regarding referrals or authorizations, member complaints, identification card requests.</li>
<li>Must Report to the Doral HQ.</li>
<li>Responsible for maintaining customer service levels (abandonment rate, speed of answer and service level) within established parameters.</li>
<li>Is knowledgeable on plans benefit, CMS and Plans policies and procedure.</li>
<li>Applies high level of subject matter knowledge to solve a variety of common business issues.</li>
<li>Provides quality services effectively to increase the overall level of customer service and satisfaction as measured by CMS.</li>
<li>Identifies the differences between a Grievance, Appeal or Coverage Decision and process the request through the appropriate channels.</li>
<li>Identify, handle, document and/or route Utilization Management inquiries appropriately</li>
<li>Identify and document Coverage Determinations.</li>
<li>Documents all inquiries and complaints.</li>
<li>Interacts with other departments about member issues or concerns.</li>
<li>Approaches work in a meticulous and thorough manner, pays attention to detail and follows company scripts.</li>
<li>Manages time effectively and prioritizes tasks to meet deadlines.</li>
<li>Assists customers, family members and others with concern and empathy; respect their confidentiality and privacy and communicate with them in a courteous and respectful manner.</li>
<li>Complies with company policies and procedures and maintains confidentiality of customer medical records in accordance with state and federal laws.</li>
<li>Ensures compliance with all HIPAA, OSHA, and other federal, state and local regulations.</li>
<li>Participates in meetings, trainings and in-service education, as required.</li>
<li>Highly regulated environment.</li>
<li>Time frames to handle issues are in accordance with CMS time frames.</li>
<li>Interacts with members, family members, staff, visitors, government agencies, etc., under a variety of conditions and circumstances.</li>
</ul>
Qualification and Education:
<ul>
<li>Minimum of High School diploma or equivalent.</li>
<li>Minimum of 1year healthcare experience is required, with a preference for plan experience.</li>
<li>Working knowledge of the Privacy and Security Health Insurance Portability and Accountability Act (HIPAA) regulations.</li>
<li>Excellent communication skills, attention to detail, ability to set priorities appropriately and meet strict deadlines and the ability to manage multiple tasks simultaneously is required.</li>
<li>Excellent listening, interpersonal, verbal and written communication skills with individuals at all levels of the organization.</li>
<li>Excellent computer knowledge is required, including proficient knowledge of Microsoft Office</li>
<li>Familiarity with healthcare laws, regulations and standards.</li>
<li>Ability to compute basic arithmetic and work with numbers.</li>
<li>Must be patient in dealing with an elderly population and sympathetic to hearing or vision deficiencies.</li>
<li>Ability to work effectively independently, work with very little supervision and in a team environment.</li>
<li>Ability to read, analyze, and interpret technical procedures or governmental regulations.</li>
<li>Ability to effectively present information and respond to questions from groups of managers, clients, customers and the general public.</li>
<li>Ability to define problems, collect data, establish facts, and draw valid conclusions.</li>
<li>Strong decision-making, analytical skills.</li>
<li>Must be self-motivated, organized and have excellent prioritization skills.</li>
<li>Must be able to work well under stressful conditions.</li>
<li>Must be able to work in a fast paced environment.</li>
<li>Fluency in English and Spanish.</li>
</ul>
 
What set us apart:
Join Solis Health Plans as a Member Services Representative (Bilingual) and become a catalyst for positive change in the lives of our members. At Solis, you will be part of a locally rooted organization deeply committed to understanding and serving our communities. If you are eager to embark on a purpose-driven career that promises growth and the chance to make a significant impact, we encourage you to explore the opportunities available at Solis Health Plans. Join us and be the difference!

Member Services Representative (Bilingual)

<h3>Job Description</h3>
Job Description
Job Title: Remote Member Services Representative
Pay: $18 an hr | Bi-weekly
Job Type:
<ul>
<li>Remote in Oklahoma</li>
</ul>
Shift Options:
<ul>
<li>8AM-5PM M-F CST</li>
</ul>
Remote Member Services Representative Overview:
<ul>
<li>
Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors. Triages resulting rework to appropriate staff. • Documents and tracks contacts with members, providers, and plan sponsors. The CSR guides the member through their members plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines. • Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion for our members' best health. • Taking accountability to fully understand the member’s needs by building a trusting and caring relationship with the member. • Anticipates customer needs. Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc. • Uses customer service threshold framework to make financial decisions to resolve member issues. • Explains member's rights and responsibilities in accordance with contract. • Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system. • Educates providers on our self-service options; Assists providers with credentialing and recredentialing issues. • Responds to requests received from Aetna's Law Document Center regarding litigation; Lawsuits. • Handles extensive file review requests. • Assists in preparation of complaint trend reports. Assists in compiling claim data for customer audits. • Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals. • Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management. • Performs review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible. Performs financial data maintenance as necessary. • Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.
</li>
</ul>
Remote Member Services Representative Qualifications:
<ul>
<li>•Must live in Oklahoma</li>
<li>High School or GED equivalent. • Customer Service experiences in a transaction-based environment such as a call center or retail location preferred, demonstrating ability to be empathetic and compassionate. • Experience in a production environment.</li>
</ul>
Remote Member Services Representative Benefits:
<ul>
<li>Benefits are available to full-time employees after 90 days of employment and include health, optical, dental, life, and short-term disability insurance.</li>
<li>A 401(k) with a company match is available for full-time employees with 1 year of service on our eligibility dates.</li>
</ul>
How to Apply:
If you are interested in this position, please apply OR submit your resume to:
Saw Hlaing | <a href="mailto:shlaing@alinestaffing.com" target="_blank">shlaing@alinestaffing.com</a> | 412-790-5425

Remote Member Services Representative (Must live in Oklahoma)

<h3>Job Description</h3>
Job DescriptionCompany Description 
At Discovery Behavioral Health, we know the best way to predict the future of healthcare is to create it.&nbsp; As a member of our growing team, you will have a voice in the creation of life-changing programs and treatment centers nationwide.&nbsp; Working collaboratively with the best and the brightest in our industry, you will be part of an innovative team of professionals committed to generating positive and remarkable outcomes for the clients we serve.
If you are looking for an organization that thrives on growth, celebrates diversity of thought, and rewards passionate execution, you’ve come to the right place.&nbsp; Because we put clients first, it is our honor to support and reward those who serve them.
Compensation&nbsp;Range: $21-23 per hour
Compensation&nbsp;will be dependent upon geographic region, education, and experience.
Our Offer to You! We are dedicated to empowering our clinicians with their professional and personal development by providing:&nbsp;&nbsp; •&nbsp;&nbsp;&nbsp; 401(k) •&nbsp;&nbsp;&nbsp; Healthcare benefits&nbsp; •&nbsp;&nbsp;&nbsp; Vacation and sick days •&nbsp;&nbsp;&nbsp; Employee referral program •&nbsp;&nbsp;&nbsp; Employee discounts to various stores, amusement parks, events, etc. •&nbsp;&nbsp;&nbsp; Continuing education (CE) programs and training •&nbsp;&nbsp;&nbsp; Weekly training opportunities&nbsp; •&nbsp;&nbsp;&nbsp; Advancement opportunities within the organization&nbsp;
Job Description 
The Appeals Support Representative role directly supports the Clinical Appeals Specialist in the administrative functions of Denials and Appeals within the Utilization Review Team.
This is a full-time remote position that will work&nbsp;Monday through Friday, 8:00am-4:30pm EST or 8:30-5:00pm EST.
Responsibilities: • Complete outbound calls to payers for status updates on retro authorization requests and appeal submissions. • Interact with third party insurance representatives and utilize online sites to review retro authorization and appeal status. • Track and confirm weekly status updates on all outstanding appeal cases until final resolution. • Request, track, and receive payer correspondence regarding approvals and denials to include acknowledgment letters and determination letters. • Organize and scan all payer determination letters in KIPU charting system and update the Clinical Appeals Specialist within 24 hours of receipt. • Document final appeal outcomes as well as case details in KIPU chart system and appeal spreadsheet. • Responsible for obtaining patient and/or guardian signatures on required payer consent forms. • Submit retro authorization requests, provide support for retro SCA projects, and follow up on retro auth submissions until final resolution. • Identify problem cases and escalate issues to Clinical Appeals Specialist as appropriate. • Attend and participate in all monthly UR Team meetings and all quarterly Denials meetings. • Adhere to privacy and HIPAA guidelines. • Perform and/or assist with special projects as assigned.
Qualifications 
• Associate’s degree required or High School Diploma plus 5-7 years of appeals and grievance experience; Bachelor’s degree preferred. • Ability to work Monday through Friday, 8:00am-4:30pm or 8:30am-5:00pm EST. • Ability to utilize and navigate Zoom and Microsoft Teams for remote meetings and IM chat. • Strong Microsoft Office skills (Excel, Word, Outlook) • Experience with insurance follow up and/or appeals and grievances required. • Familiarity with medical billing, provider relations, and/or healthcare office experience required. • Ideal candidate must be a self-starter with strong attention to detail, the ability to multi-task, a high level of organization, and excellent communication skills. • Ability to remain flexible and adapt to changing situations. • Excellent customer service skills and strong analytical skills.
Not sure if you meet all the qualifications? Apply anyway! To provide truly innovative care, we need to have a diverse team around us. That’s why Discovery Behavioral Health is committed to creating an inclusive environment. If you find yourself meeting some but not all the above, we’d be happy to consider your application.
 Additional Information 
We are proud to be an EEO employer M/F/D/V. We maintain a drug-free workplace and perform pre-employment substance abuse testing.&nbsp;All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, or national origin.
For more information about our company benefits, please visit us at discoverybehavioralhealth.com/careers/
#DBH123
Discovery Behavioral Health seeks to build a diverse staff that is reflective of the patients we serve and the communities where we work. DBH encourages multiple perspectives, experiences, and strives to hire and retain a diverse workforce.

Appeals Support Representative

<h3>Job Description</h3>
Job DescriptionAre you detail-oriented, bilingual in English and Spanish, and passionate about supporting people through complex issues? We’re looking for three dedicated professionals to join our Grievance &amp; Appeals team on a 6-month hybrid assignment that makes a real impact in people’s lives. What You’ll Do: Help ensure compliance with grievance and appeal regulations from CMS, DHCS, and DMHC. Support the investigation and resolution of member and provider concerns with care and accuracy. Draft clear, timely letters and documentation to stakeholders. Coordinate across departments to ensure timely resolution of cases. Speak directly with members to gather information and answer questions. Use LEAN principles to make our work more efficient and effective. What You Bring: Bilingual fluency in English and Spanish (written and spoken). At least 3 years of office administrative experience, including proficiency with Microsoft Office. Strong typing (45+ WPM), data entry, and organizational skills. A courteous phone manner, the ability to juggle multiple priorities, and a keen attention to detail. A team-first attitude, cultural sensitivity, and a willingness to learn and follow procedures. A high school diploma or GED. Why You’ll Love Working With Us: You’ll be part of a supportive team, working in a meaningful role that helps protect members' rights and improve service across the organization. You’ll gain valuable experience in regulatory compliance, member relations, and healthcare operations—all while being part of something bigger. EEO/AA Employer/Vet/Disabled. The Know Your Rights poster is available here: <a href="https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12.pdf" target="_blank">https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRi…</a> The pay transparency policy is available here: <a href="https://www.dol.gov/sites/dolgov/files/ofccp/pdf/pay-transp_%20English_formattedESQA508c.pdf" target="_blank">https://www.dol.gov/sites/dolgov/files/ofccp/pdf/pay-transp_%20English_…</a> For temporary assignments lasting 13 weeks or longer, the Company is pleased to offer major medical, dental, vision, 401k and any statutory sick pay where required. We are committed to working with and providing reasonable accommodations to individuals with disabilities. If you need a reasonable accommodation for any part of the employment process, please contact your staffing representative who will reach out to our HR team. AppleOne participates in the E-Verify program in certain locations as required by law. Learn more about the E-Verify program. <a href="https://e-verify.uscis.gov/web/media/resourcesContents/E-Verify_Participation_Poster_ES.pdf" target="_blank">https://e-verify.uscis.gov/web/media/resourcesContents/E-Verify_Partici…</a> We also consider qualified applicants regardless of criminal histories, consistent with legal requirements. Pursuant to applicable state and municipal Fair Chance Laws and Ordinances, we will consider for employment-qualified applicants with arrest and conviction records. For Los Angeles, CA applicants: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. #1062 Company DescriptionThis company offers growth and a great group of people to work with. 
<h3>Company Description</h3>
This company offers growth and a great group of people to work with.

19 grievance-and-appeals-representative Jobs