Customer Solution Center Appeals and Grievances Specialist II
4 days ago
Customer Solution Center Appeals and Grievances Specialist II Job Category: Customer Service Location: Los Angeles, CA, US, 90017 Position Type: Full Time Requisition ID: 11505 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. 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. Job Summary 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 regulatory requirements from CMS, DHCS, DMHC, MRMIB, and NCQA. Responsibilities include reviewing pre-service authorizations, concurrent and post-service medical necessity, benefit coverage appeals, and complex provider claim disputes. The position is responsible for maintaining the privacy and confidentiality of information, protecting the organization's assets, acting with ethics and integrity, and adhering to company policies and applicable laws and regulations. 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. Participates in internal and external oversight activities and recommends opportunities for improvement. Performs other duties as assigned. Education Required Associate's Degree or equivalent education and/or experience may be considered. Education Preferred Bachelor's Degree Experience Required: 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 and interpreting 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. Skills Required: Organized, detail-oriented, and able to exercise strong independent judgment. Conflict resolution and persuasion skills. Excellent communication and presentation skills. Proficient in MS Office applications. Strong knowledge of regulatory standards and claims processing. Preferred: Proficient in MS Access and Visio. Licenses/Certifications Required Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information Salary 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 #J-18808-Ljbffr
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Los Angeles, California, United States Scout Exchange Full timeJob DescriptionJob Title: Customer Solutions Center Appeals and Grievances Training Specialist IIJob Type: Hybrid | PermanentLocation: Los Angeles, CA (Position will be Hybrid - will be conducting combination WebEx and in near future Onsite Trainings)Required Skills:3 years experience in Healthcare Industry3 years experience designing and conducting...
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Los Angeles, California, United States Scout Exchange Full timeJob Title: Customer Solutions Center Appeals and Grievances Training Specialist IIThis role is responsible for designing and delivering training programs to enhance the skills and knowledge of the Customer Solutions Center Appeals and Grievances team.Key Responsibilities:Develop and implement training strategies to improve employee performance and...
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Los Angeles, California, United States CCG Business Solutions, LLC Full timeJob Title: Customer Solutions Center Appeals and Grievances Training Specialist IIAt CCG Business Solutions, LLC, we are seeking a highly skilled and experienced Training Specialist II to join our team. As a key member of our Customer Solutions Center Appeals and Grievances team, you will be responsible for providing ongoing training on the core processing...
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Los Angeles, United States Scout Exchange Full timeTitle - Customer Solution Center Appeals and Grievances Training Specialist II Job Type - Hybrid | Permanent Location - Los Angeles, CA (Position will be Hybrid - will be conducting combination WebEx and in near future Onsite Trainings. Person must be flexible. Person will need to be working in state remote when working from home). Required: Must have 3...
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Los Angeles, California, United States CCG Business Solutions, LLC Full timeJob Title: Customer Solutions Center Appeals and Grievances Training Specialist IIThe Customer Solutions Center Appeals and Grievances Training Specialist II is a key member of our team, responsible for providing ongoing training on the core processing system, A&G processing procedures, and regulatory changes that impact established procedures. This role...
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Los Angeles, California, United States Scout Exchange Full timeJob Summary:The Customer Solutions Center Appeals and Grievances (A&G) Training Specialist II is a key role in the department, responsible for designing and conducting training programs using established regulatory and departmental guidelines. This position provides ongoing training on the core processing system, A&G processing procedures, and regulatory...
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Los Angeles, United States L.A. Care Health Plan Full timeJob Summary The Customer Solution Center Appeals and Grievances Nurse Specialist LVN II is primarily responsible for the overall coordination of the Appeals & Grievance (A&G) program for L.A. Care Health Plan members under the direct supervision and management of the A&G Nurse Specialist, RN and/or Medical Director. This position provides assistance to...
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Los Angeles, United States L.A. Care Health Plan Full timeSalary 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...
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Appeals and Grievances Specialist II
3 weeks ago
Los Angeles, California, United States Insight Global Full timeJob SummaryWe are seeking a highly organized and detail-oriented Appeals and Grievances Specialist II to join our team at Insight Global. As a key member of our Appeals and Grievances team, you will be responsible for receiving, investigating, and resolving member and provider complaints and appeals in a timely and efficient manner.Key...
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Lead Customer Solution Center Appeals and Grievances
2 months ago
Los Angeles, United States L.A. Care Health Plan Full timeSalary Range: $67,186.00 (Min.) - $87,342.00 (Mid.) - $107,498.00 (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...
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Los Angeles, California, United States CCG Business Solutions, LLC Full timeJob DescriptionThe Customer Solutions Center Appeals and Grievances (A&G) Training Specialist II is responsible for providing ongoing training on the core processing system, A&G processing procedures, training regulatory changes which will affect established procedures, working with the quality team on quality and performance guidelines, creating and...
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Appeals and Grievances Resolution Specialist
2 weeks ago
Los Angeles, California, United States Insight Global Full timeJob Summary: We are seeking a highly skilled Appeals and Grievances Specialist II to join our team at Insight Global. As a key member of our Appeals and Grievances team, you will play a critical role in receiving, investigating, and resolving member and provider complaints and appeals.Key Responsibilities:Support the Appeals and Grievances team in receiving,...
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Appeals and Grievances Specialist I
3 weeks ago
Los Angeles, California, United States Insight Global Full timeJob SummaryWe are seeking a highly skilled Appeals and Grievances Specialist I to join our team at Insight Global. As a key member of our Customer Solution Center, you will play a critical role in receiving, investigating, and resolving member and provider complaints and appeals.Key ResponsibilitiesInvestigate and resolve less complex appeals and grievances...
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Appeals & Grievances Supervisor
3 weeks ago
los angeles, United States Insight Global Full timeOne of our top clients in Downtown Los Angeles is looking for an Appeals & Grievances Supervisor to join their team mostly remote (on-site 2 days/month expected)!Required Skills and Experience: 3+ years’ experience in a healthcare setting in Grievances and Appeals, Compliance, Claims or Call Center.2+ years’ experience leading process, program, or staff...
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Appeals & Grievances Supervisor
1 month ago
Los Angeles, United States Insight Global Full timeOne of our top clients in Downtown Los Angeles is looking for an Appeals & Grievances Supervisor to join their team mostly remote (on-site 2 days/month expected)!Required Skills and Experience: 3+ years’ experience in a healthcare setting in Grievances and Appeals, Compliance, Claims or Call Center.2+ years’ experience leading process, program, or staff...
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Appeals & Grievances Supervisor
4 weeks ago
Los Angeles, United States Insight Global Full timeOne of our top clients in Downtown Los Angeles is looking for an Appeals & Grievances Supervisor to join their team mostly remote (on-site 2 days/month expected)!Required Skills and Experience: 3+ years’ experience in a healthcare setting in Grievances and Appeals, Compliance, Claims or Call Center.2+ years’ experience leading process, program, or staff...
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Appeals & Grievances Supervisor
1 month ago
Los Angeles, United States Insight Global Full timeOne of our top clients in Downtown Los Angeles is looking for an Appeals & Grievances Supervisor to join their team mostly remote (on-site 2 days/month expected)!Required Skills and Experience: 3+ years’ experience in a healthcare setting in Grievances and Appeals, Compliance, Claims or Call Center.2+ years’ experience leading process, program, or staff...
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Appeals and Grievances Team Lead
1 month ago
Los Angeles, California, United States Insight Global Full timeJob Title: Appeals and Grievances SupervisorThe Appeals and Grievances Supervisor plays a critical role in ensuring the efficient resolution of appeals and grievances within the Customer Solution Center. This position involves leading a team of professionals who handle the intake, research, resolution, tracking, and reporting of appeals and grievances.Key...
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Appeals and Grievances Specialist I
2 weeks ago
Los Angeles, California, United States Insight Global Full timeJob SummaryThe Appeals and Grievances Specialist I will support the Appeals and Grievances team in receiving, investigating, and resolving member and provider complaints and appeals. This role will escalate complex issues or questions to leadership as appropriate.Key ResponsibilitiesLearn the specialty level appeals and grievances work by resolving less...
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Healthcare Appeals and Grievances Manager
2 weeks ago
Los Angeles, California, United States Insight Global Full timeJob SummaryThe Appeals and Grievances Supervisor is responsible for leading a team that handles appeals and grievances in the healthcare industry. This role involves supervising and supporting team members, monitoring research and resolution of appeals and grievances, and ensuring thorough investigations are completed according to company policies and...
