Supervisor, Customer Solution Center Appeals and Grievances

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

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  5190

 

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 Supervisor, Customer Solution Center Appeals & Grievances is responsible for direct supervision and support of the team responsible for the intake, research, resolution, tracking, trending and reporting within the Appeals & Grievances department. This position will be accountable for leading and directing the work for the Appeals & Grievances department by monitoring the research, negotiation and resolution of all types of appeals and grievances to ensure thorough investigations are completed as outlined in the company policies and procedures. Provides support and ownership of cases identified as escalated, complex and/or multi-issue appeals and grievances on an as needed basis. Collaborates with internal departments to ensure timely resolution. This position will be responsible for analyzing and trending for all appeals and grievances. Responsible for the development and maintenance of the appeal and grievance Policies and Procedures, workflows, Member correspondence, and training as needed, or on an annual basis. 

Duties

Evaluates daily reports to ensure individual and team Key Performance Indicators (KPIs), SLAs, Performance Scorecards meet regulatory requirements.        

Provide direction to staff for complex/sensitive member and provider inquiries, concerns, complaints, appeals, and grievances. Conduct weekly 1:1s with direct reports.
    
Builds and maintains strong working relationships with internal departments involved in appeal and grievance resolution.        

Development, maintenance and implementation of P&Ps, workflow and training.      
  
Audit preparation and providing recommendations for Corrective Action Plans from state regulatory agencies.

 

Performs other duties as assigned. 

Education Required
Bachelor's Degree
In lieu of degree, equivalent education and/or experience may be considered.
Education Preferred
Master's Degree
Experience

Required:
At least 3-5 years in a healthcare setting in Grievances and Appeals, Compliance, Claims or Call Center.

 

At least 2-3 years lead/supervisory experience.

 

Preferred:
Previous experience in Managed Health, preferably in Customer Service, Appeals and Grievances and/or Claims.

Skills


Required:
Ability to manage and organize large volumes of data.

 

Knowledge of regulatory and accreditation entities and their requirements.

 

Excellent verbal and written communication skills and interpersonal skills.

 

Good working knowledge of licensure and regulatory requirements, and accreditation standards.

 

Ability to work independently.

 

Ability to solve complex issues and identify creative solutions.

 

Computer ease and literacy with Microsoft Office (Word, Excel, Power Point, Access,  and Visio).

 

Preferred:
Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.

Licenses/Certifications Required
Licenses/Certifications Preferred
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, Call Center Manager, Call Center Supervisor, Call Center, Healthcare, Insurance, Customer Service