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Customer Solution Center Appeals and Grievances Specialist II
1 month ago
Job Category: Customer Service
Location: Los Angeles, CA, US, 90017
Position Type: Full Time
Requisition ID: 11145
Salary Range: $60,778.00 (Min.) - $75,950.00 (Mid.) - $91,166.00 (Max.)
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.
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.
The Customer Solution Center Appeals and Grievances (A&G) Specialist II 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, MRMIB, and NCQA regulatory requirements. Responsibilities include reviewing pre-service authorizations, concurrent and post-service medical necessity, benefit coverage appeals, 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, and adhering to company policies and procedures.
Duties- Identifies, investigates, and resolves administrative complaints, complex provider appeals, and State Fair Hearing adhering to CMS, DHCS, DMHC, MRMIB, and NCQA standards and regulations.
- Intakes, acknowledges, prepares case files, and routes complaints to appropriate internal departments for investigation and resolution.
- Ensures integrity of A&G database by thorough, timely, and accurate assignment of cases.
- 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.
- Performs other duties as assigned.
Associate's Degree, or equivalent education and/or experience may be considered.
Education PreferredBachelor's Degree
ExperienceRequired:
- At least 2 years of experience in Managed Care with specific experience in resolving member and provider complaint and appeals issues.
- Experience working with firm deadlines, able to interpret and apply regulations.
- At least 5 years of experience in Managed Care working with Medicare, Medi-Cal, and other State Sponsored programs.
- Knowledge of medical terminology and strong advocacy experience.
Required:
- Must be organized, detail-oriented, and able to exercise strong independent judgment.
- Possesses conflict resolution and persuasion skills.
- A team player with excellent communication and presentation skills.
- Proficient in MS Office applications, including Word, Excel, and PowerPoint.
- Requires strong knowledge of regulatory standards and claims processing.
Preferred:
Proficient in MS Office applications, Access, Visio.
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Additional InformationSalary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including:
- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental, and Vision
- Wellness Program
Nearest Major Market: Los Angeles
Job Segment: Claims, Medicare, Medicaid, Healthcare, Insurance
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