Customer Solution Center Appeals and Grievances Specialist I

Job Summary

The Customer Solution Center Appeals and Grievances Specialist I primary function is to learn the specialty level appeals and grievances work supporting the higher level position in this class series to ensure positive outcomes for members. It will support the Appeals and Grievances team to receive, investigate and resolve member and provider complaints and appeals; escalates complex issues or questions to leadership team as appropriate.

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

Primary function of this role is to learn the specialty level appeals and grievances work by resolving less complex cases to ensure positive outcomes for members. (20%)

Supports the identification, investigation and resolve administrative complaints, simple appeals while adhering to Center for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MRMIB) and National Committee for Quality Assurance (NCQA) standards and regulations. (20%)

Intakes, acknowledges, prepares case files and routes complaints to appropriate internal departments and external business partners for investigation and resolution, exercising strong independent judgment. (20%)

Processes assigned cases accurately and in a timely manner per instructions. Escalates complex issues or questions to leadership as appropriate. (20%)

Actively participates in team meetings and provides recommendation for improvement as appropriate based on discoveries. (10%)

Performs other duties as assigned. (10%)

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 1 year of experience in Managed Care working with Medicare, Medi-Cal and other State Sponsored programs.

Experience working with firm deadlines, able to interpret and apply regulations. 

Strong advocacy experience.

Skills

Required:
Must be organized, detail oriented, able to exercise strong independent judgment; poses conflict resolution and persuasion skills.  

A team player with excellent communication and presentation skills, able to work effectively with various internal departments/service areas, plan partners, participating provider groups and other external agencies.
  
Proficient in MS Office applications including Word, Outlook and Excel. 

Ability to provide confidentiality and professional customer service skills. 

Ability to work under tight deadline.

Strong analytical, verbal, written and presentation skills, able to monitor and be compliant with strict regulatory deadlines. 

Knowledge of Medical terminology.

Preferred:
In depth knowledge of DHCS, NCQA, CMS, DMHC regulartories and guidelines.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information

This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call.

This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned