CSC Senior A&G Specialist

Job Category:  Customer Service
Department:  CSC Appeals & Grievance
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  2571

 

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Job Summary


The CSC Senior Appeal and Grievances Specialist will receive, investigate and resolve member and provider complaints and appeals exercising strong independent judgment.  This position will provide resolution of complaints in compliance with CMS, DHCS, DMHC, MBMIB and NCQA regulatory requirements. The position reviews pre-service authorizations, concurrent and post-service (retroactive review) medical necessity; benefit coverage appeals and reconsiderations, and complex provider claim disputes. The position is responsible for monitoring the caseloads of the Grievance Specialists and ensuring timely and accurate closure of grievances to meet regulatory requirements. The position is also responsible for overseeing the case resolution process and conducting quality checks to ensure that resolutions meet regulatory and internal requirements. The position is further responsible for tracking, trending and reporting complaints and appeals, as well as participating in internal and external oversight activities.
The position is responsible for maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting noncompliance, adhering to company policy and procedures, including accreditation requirements, applicable federal, state and local laws and regulations.

Duties

● Contacts members as needed to investigate, coordinate care and support resolutions for clinical and non-clinical cases.

● Identifies, investigates, and resolves administrative complaints, complex provider appeals and State Fair Hearing cases adhering to CMS, DHCS, DMHC, MRMIB and NCQA standards and regulations.

● Intakes, acknowledges, prepares case files and routes complaints to appropriate internal department for investigation and resolution, exercising strong independent judgment. Oversees members' case files in the applicable database/system to ensure that files are accurate and complete. Oversees caseloads for assigned specialists and provides coverage for assigned specialists who are absent.

● Monitors daily/weekly/monthly grievance reports to ensure timeliness of case closures to meet internal and external reporting requirements. Prepares and analyzes monthly appeal and grievance reports to meet internal and external reporting requirements.

● Participates in internal and external oversight activities, inter-rater reliability reviews and focused audits.  Recommends opportunities for improvement.

● Performs outreach to internal departments, Plan Partners, IPA/PPGs, facilities and vendors to gather information, medical records and other documentation as needed by nurse and in compliance with PP/PPG contracts.

● Completes non-clinical aspects of Clinical Grievance Resolution Letter using appropriate template for type of case and LOB. Provides completed letter with attachments for nurse to approve. Arranges for translation of letter, if required, in time to meet regulatory timelines. Mails letter using department protocols.

● Performs other duties as assigned.

Education

High School Diploma/GED

Associate's Degree or Bachelor's Degree

Experience


Required:
● With High School Diploma:  5+ years experience in Managed Care with specific experience in resolving member and provider complaint and appeals issues, including eligibility, access to care, claims, benefit, and quality of care concerns. 
 
● Experience working with firm deadlines, able to interpret and apply regulations. 

Preferred:
● With Associate's Degree:  2-4 years experience in Managed Care with specific experience in resolving member and provider complaint and appeals issues, including eligibility, access to care, claims, benefit, and quality of care concerns.  

● 5-10 years experience in Managed Care working with Medicare, Medi-Cal and other State Sponsored programs. 

● Knowledge of Medical terminology and strong advocacy experience.

Professional Licenses

Professional Certifications

Required Training

Additional Information

L.A. Care offers a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)


Nearest Major Market: Los Angeles

Job Segment: Medical, Claims, Medicare, Healthcare, Insurance