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Grievance Resolution Specialist

4 months ago

Orange, United States Equiliem Full time

Client Summary:

Our client is the single largest health plan in Orange County, serving one in four residents. Our motto -

"Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health.

Job Description: Grievance Resolution Specialist

The Grievance Resolution Specialist will be responsible for coordinating the grievance and appeal resolution process. The incumbent will respond to verbal and written grievances and appeals from members and providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, and pharmacy and vision decisions. The incumbent will have frequent external contact with members and families, health care providers, health networks, third party administrators, and regulators. The incumbent will collaborate with internal departments such as Customer Service, Provider Relations, Pharmacy, and Medical Management to identify factors necessary for the optimal resolution of Grievances and Appeals.

Duties & Responsibilities: 80% - Program Support

Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.

Maintains adequate information in the company's Health's systems; ensures data collection, summarization, integration, and reporting, including case creation and management and events/activity tracking.

Gathers pertinent information regarding the grievances and appeals received, including member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal, or supplemental information required to evaluate grievances and appeals within regulatory requirements.

Coordinates and participates in case discussions with operational experts to result in a final case disposition as needed.

Evaluates case details, proposes recommendations, or makes decisions as applicable, ensures the organization's decision is implemented according to the Grievance and Appeals policies and case resolution.

Develops resolution letters and correspondence to members and providers.

Communicates with internal and external customers to ensure timely review and resolution of grievances or appeals.

15% - Administrative Support

Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.

Assists with health networks' compliance process.

Meets performance measurement goals for Grievance and Appeals Resolution Services (GARS).

Identifies trends and root cause of issues, proposes solutions, or escalates ongoing issues to management.

5% - Completes other projects and duties as assigned.

Minimum Qualifications:

High School diploma or equivalent required.

1 year of experience in any of the following areas: Grievances and Appeals, Claims, Regulatory Compliance, Customer Service, or related field required.

Preferred Qualifications:

Associate's degree in business, health care administration, or related field.

Experience in health care practice standards for both government and commercial plans.

Bilingual in English and in one of the company's Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).

Knowledge & Abilities:

Develop rapport and establish and maintain effective working relationships with the company's Health's leadership and staff and external contacts at all levels and with diverse backgrounds.

Work independently and exercise sound judgment.

Communicate clearly and concisely, both orally and in writing.

Work a flexible schedule; available to participate in evening and weekend events.

Organize, be analytical, problem-solve, and possess project management skills.

Work in a fast-paced environment and in an efficient manner.

Manage multiple projects and identify opportunities for internal and external collaboration.

Motivate and lead multi-program teams and external committees/coalitions.

Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Physical Requirements (With or Without Accommodations):

Ability to visually read information from computer screens, forms, and other printed materials and information.

Ability to speak (enunciate) clearly in conversation and general communication.

Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.

Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling, and prolonged sitting.

Lifting and moving objects, patients, and/or equipment 10 to 25 pounds.

Work Environment:

If located at the 500, 505 Building or a remote work location:

Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.

There are no harmful environmental conditions present for this job.

The noise level in this work environment is usually moderate.

Schedule Notes:

TBD. Equiliem Healthcare

specializes in staffing clinical, non-clinical, and allied personnel. We excel in all levels, disciplines, and specialties within the healthcare spectrum. Our projects range from short to long term local and travel assignments. Equiliem has been recognized as a certified small business enterprise. In addition, we are proud that we have earned the prestigious Joint Commission accreditation for staffing firms and have been awarded Best in Staffing 4 years running by our employees and client partners.

Benefits offered to our workers include the following:

Medical Insurance

Vision & Dental insurance

Life Insurance

401K

Commuter Benefits

Employee Discounts & Rewards

Payroll Payment Options

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