Senior Appeals and Grievances Specialist

Job Category:  Administrative, HR, Business Professionals
Department:  CSC Appeals & Grievance (348)
Location: 

Los Angeles HQ, California, US

Position Type:  Full Time
Requisition ID:  472

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.

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.

QUALIFICATION AND REQUIREMENTS

EDUCATION
Required
High School Diploma

Preferred
Associate's Degree in  Health Care Administration or Medical Assistant

EXPERIENCE
Required

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.

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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