Appeal & Grievance Specialist

Job Category:  Administrative, HR, Business Professionals
Department:  CSC Appeals & Grievance (348)
Location:  Los Angeles HQ, California, US
Position Type:  Full Time
Requisition ID:  469

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.

DUTIES
The CSC A&G Specialist (A&G 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 A&G Specialist 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 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.

QUALIFICATIONS AND REQUIREMENTS

EDUCATION
Required
High School Diploma

Preferred
Bachelor's Degree

EXPERIENCE
Required
With High School Diploma: 4-5 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.  
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, Word, Excel and Power Point. 
Requires strong knowledge of regulatory standards and claims processing; strong analytical, oral, written and presentation skills, able to monitor and be compliant with strict regulatory deadlines. 
 
Preferred:  
With Associate's Degree: 3-4 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.  

With Bachelor's Degree: 2 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.
Proficient in MS Office applications, Access, Visio.

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

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


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