Grievance Resolution Specialist Provider Resolution

Grievance Resolution Specialist (Provider Resolution)

Job Title: Grievance Resolution Specialist (Provider Resolution)

Location: Orange County, CA (500 City Parkway West)

Work Schedule: Monday Friday | 8:00 AM 5:00 PM

Work Setting: 100% Onsite

We are seeking a detail-oriented Grievance Resolution Specialist (Provider Resolution) to support the Grievance & Appeals department. In this role, you will investigate provider grievances and appeals, coordinate with internal teams, communicate with providers, and ensure timely, accurate case resolution while maintaining compliance with healthcare regulations.

• Review and process provider grievances and appeals.
• Gather, analyze, and document case information.
• Create and maintain accurate case records and reports.
• Communicate with providers and internal departments regarding case status.
• Research provider contracts, policies, and regulatory requirements.
• Draft professional resolution letters and correspondence.
• Respond to provider inquiries by phone and email.
• Coordinate with operational teams to resolve complex issues.
• Identify trends and recommend process improvements.
• Maintain confidentiality and comply with healthcare regulations.
• Perform additional administrative duties as assigned.

• High School Diploma or GED.
• At least 1 year of experience in one or more of the following:
  • Provider Dispute Resolution
  • Medicare or Medi-Cal Appeals
  • Grievance & Appeals
  • Claims Administration
  • Regulatory Compliance
  • Healthcare Customer Service
• Strong written and verbal communication skills.
• Ability to work independently and manage multiple priorities.
• Proficiency in Microsoft Office (Word, Excel, Outlook, PowerPoint).

• Associate degree in Business, Healthcare Administration, or a related field.
• Experience with healthcare practice standards for government and commercial health plans.
• Bilingual candidates (Spanish, Vietnamese, Chinese, Korean, Arabic, Farsi, or Russian) are encouraged to apply.

• Strong analytical and problem-solving abilities
• Excellent organizational skills
• Attention to detail
• Ability to manage multiple cases simultaneously
• Professional customer service skills
• Team-oriented with the ability to build positive working relationships