Current jobs related to Customer Solution Center Appeals and Grievances Specialist II - Los Angeles - L.A. Care Health Plan
-
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...
-
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...
-
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...
-
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...
-
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...
-
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...
-
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...
-
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...
-
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...
-
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,...
-
Los Angeles, United States L.A. Care Health Plan Full timeJob 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 Centers for Medicare and Medicaid Services (CMS), California Department of...
-
Appeals and Grievances Specialist II
2 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...
-
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...
-
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...
-
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...
-
Appeals and Grievances Supervisor
1 month ago
Los Angeles, United States Mitchell Martin Inc. Full timeJob summary:The Supervisor, Customer Solution Center Appeals & Grievances is responsible for direct supervision and support of the team responsible for the intake, research, resolution, tracking, trending and reporting within the Appeals & Grievances department.This position will be accountable for leading and directing the work for the Appeals & Grievances...
-
Appeals and Grievances Resolution Specialist
3 days 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,...
-
Appeals and Grievances Manager
1 month ago
Los Angeles, California, United States Mitchell Martin Inc. Full timeJob SummaryThe Appeals and Grievances Supervisor is responsible for leading and directing the work of the Appeals & Grievances department. This includes monitoring research, negotiation, and resolution of appeals and grievances to ensure thorough investigations are completed in accordance with company policies and procedures.Key ResponsibilitiesDirect...
-
Appeals and Grievances Specialist I
2 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...
-
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...
Customer Solution Center Appeals and Grievances Specialist II
2 months ago
Customer Solution Center Appeals and Grievances Specialist II (ALD)
Job Category: Customer Service
Department: CSC Appeals & Grievances
Location:
Los Angeles, CA, US, 90017
Position Type: Full Time
Requisition ID: 11362
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 nations largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.
Mission: L.A. Cares mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
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 Centers for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MBMIB) and National Committee for Quality Assurance (NCQA) regulatory requirements. This position reviews pre-service authorizations, concurrent and post-service (retroactive review) medical necessity; benefit coverage appeals and reconsiderations, 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, adhering to company policy and procedures, including accreditation requirements, applicable federal, state and local 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 department for investigation and resolution, exercising strong independent judgment.
Ensures integrity of A&G database by thorough, timely and accurate assignment of cases. Monitors closure of complaints and works with Quality Control Supervisor to resolve all database issues.
Prepare and analyze 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. Recommends opportunities for improvement
Perform other duties as assigned.
Duties Continued
Education Required
Associate's Degree
In lieu of degree, 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, including eligibility, access to care, claims, benefit, and quality of care concerns.
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, able to exercise strong independent judgment; poses conflict resolution and persuasion skills.
A team player with excellent communication and presentation skills, able to work effectively with various internal departments/service areas, plan partners, participating provider groups and other external agencies.
Proficient in MS Office applications, Word, Excel and Power Point.
Requires strong knowledge of regulatory standards and claims processing; strong analytical, oral, written and presentation skills, able to monitor and be compliant with strict regulatory deadlines.
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.
This position is a limited duration position. The term of this position is a minimum one year and maximum of two years from the start date unless terminated earlier by either party. Limited duration positions are full-time positions and are eligible to receive full benefits.
L.A. Care offers a wide range of benefits including
Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)
