Grievance and Appeals Coordinator
2 weeks ago
Responsible for the research and documentation of written and verbal complaints and appeals filed by members to the respective health plan. The coordinator is responsible for identifying the issues and categorizing and entering the information into a database.
Duties and Responsibilities
1. Responsible for handling of assigned appeals and grievances by inputting into appropriate databases, writing acknowledgement letters, obtaining medical records as needed, researching cases, resolving issues and faxing resolution letters while ensuring that regulatory time frames are met.
2. Works with the CMO and other clinical staff to ensure that clinical issues are appropriately evaluated
3. Answers telephone inquiries and maintains a professional level of telephone etiquette
4. Responds to questions from authorized representatives, providers, and appropriate internal staff regarding grievances and appeals
5. Works closely with internal departments to resolve and research member and provider reconsideration, contacts providers and external agencies to obtain additional information to adequately resolve and respond to the reconsiderations and grievances.
6. Responsible for investigating and resolving all priority issues and/or concerns in a timely and efficient manner
7. Responsible for formulating/implementing and executing all processes, requests, workflows or policies as requested by management in a courteous and efficient manner, including offering a proactive approach to suggestions and recommendations
8. Other related duties, as assigned
9. Actively participates in self-development programs
Minimum Job Requirements
· High School graduate or GED equivalent
· Minimum one year experience working in a appeals and grievances department
· Attention to detail and accuracy and capability of meeting deadlines consistently
Skill and Abilities
· Effective verbal and written communication skills and effective interpersonal skills.
· Excellent organizational skills and ability to multitask
· Ability to work well in a busy department
· Able to stay focused on the telephone even with noise and other distractions
· Minimum or higher proficiency level with Microsoft Office Programs; primarily Word and Excel 2013 or higher
· EZ-CAP® knowledge a plus.
-
Appeals and Grievances Manager
23 hours ago
Los Angeles, California, United States Insight Global Full timeJob SummaryThe Appeals and Grievances Supervisor is responsible for overseeing the Appeals and Grievances department, ensuring thorough investigations are completed according to company policies and procedures. This role involves leading and directing the team's work, monitoring research, negotiation, and resolution of all types of appeals and grievances....
-
Appeals and Grievances Manager
23 hours ago
Los Angeles, California, United States Insight Global Full timeJob SummaryThe Appeals and Grievances Supervisor is responsible for overseeing the Appeals and Grievances department, ensuring thorough investigations are completed according to company policies and procedures. This role involves leading and directing the team's work, monitoring research, negotiation, and resolution of all types of appeals and grievances.Key...
-
Appeals and Grievances Supervisor
4 weeks ago
Los Angeles, United States Insight Global Full timeThe Appeals and Grievances Supervisor is responsible for direct supervision and support of the team responsible for the intake, research, resolution, tracking, trending and reporting within the Appeals and Grievances department. This position will be accountable for leading and directing the work for the Appeals and Grievances department by monitoring the...
-
Appeals and Grievances Supervisor
1 month ago
Los Angeles, United States Insight Global Full timeThe Appeals and Grievances Supervisor is responsible for direct supervision and support of the team responsible for the intake, research, resolution, tracking, trending and reporting within the Appeals and Grievances department. This position will be accountable for leading and directing the work for the Appeals and Grievances department by monitoring the...
-
Grievance and Appeals Operations Manager
2 weeks ago
Los Angeles, California, United States Insight Global Full timeJob OverviewThe Grievance and Appeals Operations Manager is tasked with overseeing and guiding the team responsible for the reception, investigation, resolution, monitoring, analysis, and reporting within the Grievances and Appeals division. This role is pivotal in steering the efforts of the department by ensuring comprehensive investigations are conducted...
-
Appeals and Grievances Specialist
6 days ago
Los Angeles, California, United States L.A. Care Health Plan Full timeJob SummaryThe Customer Solution Center Appeals and Grievances 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 regulatory requirements, including CMS, DHCS, DMHC, MRMIB and NCQA standards.This position...
-
Appeals and Grievances Specialist
6 days ago
Los Angeles, California, United States L.A. Care Health Plan Full timeJob SummaryThe Customer Solution Center Appeals and Grievances 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 regulatory requirements, including CMS, DHCS, DMHC, MRMIB and NCQA standards.This position...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, 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, we make...
-
Los Angeles, United States L.A. Care Health Plan Full timeSalary Range: $77,265.00 (Min.) - $100,445.00 (Mid.) - $123,625.00 (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...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $77, Min.) - $100, Mid.) - $123, 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, we make...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $77, Min.) - $100, Mid.) - $123, 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, we make...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $77, Min.) - $100, Mid.) - $123, 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, we make...
-
Appeals and Grievances Specialist
1 week ago
Los Angeles, California, United States L.A. Care Health Plan Full timeJob SummaryThe Customer Service Representative II plays a critical role in ensuring that member and provider complaints and appeals are resolved in a timely and fair manner. This position requires strong independent judgment, conflict resolution, and persuasion skills to resolve complex issues.Key ResponsibilitiesInvestigate and resolve administrative...
-
Los Angeles, United States L.A. Care Health Plan Full timeSalary Range: $77,265.00 (Min.) - $100,445.00 (Mid.) - $123,625.00 (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...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, Max.)PLEASE NOTE: This position will work Sunday thru Thursday, 7 a.m. to 4 p.m. PST, with rotating holidays. At this time, we are only considering those candidates that live in the Pacific Time Zone.Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to...
-
Los Angeles, United States L.A. Care Health Plan Full timeSalary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)PLEASE NOTE: This position will work Wednesday - Sunday, 7 a.m. to 4 p.m. PST, with rotating holidays. At this time, we are only considering those candidates that live in the Pacific Time Zone.Established in 1997, L.A. Care Health Plan is an independent public agency...
-
Los Angeles, United States L.A. Care Health Plan Full timeSalary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)PLEASE NOTE: This position will work Sunday thru Thursday, 7 a.m. to 4 p.m. PST, with rotating holidays. At this time, we are only considering those candidates that live in the Pacific Time Zone.Established in 1997, L.A. Care Health Plan is an independent public agency...
-
Los Angeles, United States L.A. Care Health Plan Full timeSalary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)PLEASE NOTE: This position will work Monday - Friday, 7 a.m. to 4 p.m. PST, with rotating weekends and holidays. At this time, we are only considering those candidates that live in the Pacific Time Zone.Established in 1997, L.A. Care Health Plan is an independent public...
-
Los Angeles, United States L.A. Care Health Plan Full timeSalary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)PLEASE NOTE: This position will work Tuesday - Saturday, 7 a.m. to 4 p.m. PST, with rotating holidays. At this time, we are only considering those candidates that live in the Pacific Time Zone.Established in 1997, L.A. Care Health Plan is an independent public agency...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, Max.) PLEASE NOTE: This position will work Tuesday - Saturday, 7 a.m. to 4 p.m. PST, with rotating holidays. At this time, we are only considering those candidates that live in the Pacific Time Zone. Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to...
