Position Details
Grievance Resolution Specialist Apply
Client: CalOptima Health
Job Title: Grievance Resolution Specialist
Duration: 06 Months
Start Date: ASAP
Location: 505 City Parkway West, Orange, 92868 CA (Onsite)
Position Type: Contract
Interview Type: In Person/Web Interview
Ceipal ID: CAL_HD297_IK
Job Summary
- CalOptima Health is seeking a highly motivated and experienced TEMP - Grievance Resolution Specialist to join our team. The Grievance Resolution Specialist will be responsible for coordinating the grievance and appeal resolution process. The incumbent will respond to verbal and written grievances and appeals from members and providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, and pharmacy and vision decisions. The incumbent will have frequent external contact with members and families, health care providers, health networks, third party administrators, and regulators. The incumbent will collaborate with internal departments such as Customer Service, Provider Relations, Pharmacy, and Medical Management to identify factors necessary for the optimal resolution of Grievances and Appeals.
Duties & Responsibilities:
- 80% - Program Support
- Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.
- Maintains adequate information in CalOptima Health's systems; ensures data collection, summarization, integration, and reporting, including 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, 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.
- 15% - Administrative Support
- Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
- Assists with health networks' compliance process.
- Meets performance measurement goals for Grievance and Appeals Resolution Services (GARS).
- Identifies trends and root cause of issues, proposes solutions, or escalates ongoing issues to management.
- 5% - Completes other projects and duties as assigned.
Minimum Qualifications:
- High School diploma required.
- 5 years of health care/managed care experience required. Preferably in the following related areas of responsibility: Grievances and Appeals, Utilization Management and / or Quality Management.
- An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
Preferred Qualifications:
- Associate's 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).
Knowledge & 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.
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