Customer Solution Center Appeals and Grievances Specialist II
2 months 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: 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. 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, 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. Skills 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. 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 CCG Business Solutions, LLC Full timeJob OverviewCelebrate your passion for learning and development by joining CCG Business Solutions, LLC as a Customer Solutions Center Appeals and Grievances Training Specialist II. With our company's commitment to empowering individuals and fostering success, you will have the opportunity to design and deliver comprehensive training programs that boost...
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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, CA, United States L.A. Care Health Plan Full timeCustomer 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...
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Los Angeles, CA, United States L.A. Care Health Plan Full timeCustomer Solution Center Appeals and Grievances Specialist II 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...
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Los Angeles, CA, United States L.A. Care Health Plan Full timeCustomer Solution Center Appeals and Grievances Nurse Specialist LVN II Job Category: Clinical Location: Los Angeles, CA, US, 90017 Position Type: Full Time Requisition ID: 11735 Salary 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...
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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 members, we make...
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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 members, we make...
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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 members, we make...
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Los Angeles, CA, United States L.A. Care Health Plan Full timePress Tab to Move to Skip to Content Link Select how often (in days) to receive an alert: Customer Solution Center Appeals and Grievances Nurse Specialist RN II Job Category: Clinical Location:Los Angeles, CA, US, 90017 Position Type: Full Time Requisition ID: 11762 Salary Range: $88,854.00(Min.) -$115,509.00(Mid.) -$142,166.00(Max.) PLEASE NOTE: This...
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Los Angeles, California, United States CCG Business Solutions, LLC Full timeJob SummaryThe Customer Solutions Center Appeals and Grievances (A&G) Training Specialist II is a crucial role within CCG Business Solutions, LLC. As a subject matter expert in training and development, you will be responsible for creating and delivering high-quality training programs that drive business results.In this role, you will work closely with the...
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Appeals and Grievances Training Program Manager
3 weeks ago
Los Angeles, California, United States CCG Business Solutions, LLC Full timeJob Description:The Customer Solutions Center Appeals and Grievances Training Specialist II plays a critical role in ensuring that staff have the necessary skills and knowledge to perform their duties effectively. This includes providing ongoing training on core processing systems, A&G processing procedures, and regulatory changes that affect established...
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Specialist, UM Grievance and Appeals
1 month ago
Los Angeles, United States MedPOINT Management Full timeJob DescriptionJob DescriptionSummaryThe UM Grievance and Appeals Specialist role is to manage and coordinate the grievance and appeals process related to medical services provided by our organization. The coordinator will ensure timely resolution of grievances and appeals while maintaining compliance with regulatory requirements and organizational policies....
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Training Specialist for Appeals and Grievances
3 weeks ago
Los Angeles, California, United States Scout Exchange Full timeWe are looking for a seasoned Training Specialist for Appeals and Grievances to join our team at Scout Exchange. This is a full-time position with an estimated annual salary of $80,000-$105,000, depending on experience.Key Responsibilities:The Training Specialist for Appeals and Grievances will be responsible for designing and delivering training programs...
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Specialist, UM Grievance and Appeals
3 weeks ago
Los Angeles, United States MEDPOINT MANAGEMENT Full timeJob DescriptionJob DescriptionSummaryConsidering making an application for this job Check all the details in this job description, and then click on Apply.The UM Grievance and Appeals Specialist role is to manage and coordinate the grievance and appeals process related to medical services provided by our organization. The coordinator will ensure timely...
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Los Angeles, California, United States Scout Exchange Full timeJob DescriptionIn this challenging role, you will be responsible for developing and delivering training programs to enhance the performance of the Customer Solutions Center A&G team. As a key member of our team, you will design and conduct training sessions to ensure that staff have the necessary skills and knowledge to provide excellent customer service.Key...
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Los Angeles, United States L.A. Care Health Plan Full timeCustomer Solution Center Compliance Audit Specialist II Job Category: Customer Service Department: CSC Appeals & Grievances Location: Los Angeles, CA, US, 90017 Position Type: Full Time Requisition ID: 11036 Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public...
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Los Angeles, California, United States CCG Business Solutions, LLC Full timeJob Overview:Customer Solutions Center Appeals and Grievances Training Specialist II is responsible for designing, developing, and delivering comprehensive training programs to enhance the skills and knowledge of staff. The role involves working closely with department management to identify training needs and develop curriculum that meets regulatory...
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Appeals and Grievances Analyst
4 weeks ago
Los Angeles, CA, United States Acord (association For Cooperative Operations Research And Development) Full timeDescription As the Appeals and Grievances (A&G) Analyst, you will be responsible for assisting with all operational aspects of appeals and grievances, in accordance with state and federal regulations. You will: Manage various weekly/monthly deadlines effectively due to the time constraints imposed by CMS on Medicare appeals and grievances. Collaborate...
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Los Angeles, United States L.A. Care Health Plan Full timeCustomer Solution Center Audit Readiness Specialist II Job Category: Customer Service Location: Los Angeles, CA, US, 90017 Position Type: Full Time Requisition ID: 11036 Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California...
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Customer Solutions Center A&G Training Lead
5 days ago
Los Angeles, California, United States CCG Business Solutions, LLC Full time**Job Description:**The Customer Solutions Center Appeals and Grievance (A&G) Training Specialist II role involves developing and delivering comprehensive training programs to ensure employees have the necessary skills and knowledge to perform their jobs effectively.**Key Responsibilities:**Designing and implementing training curricula that meet the needs of...
