Grievance and Appeal Administrative Specialist

2 weeks ago

Santa Barbara, United States Cencal Health Full time
Job Details

Job Location
Main Office - Santa Barbara, CA

Position Type
Full Time

Job Category
Member Services

Description

Salary:$22.56/hour - $31.00/hour

Under the supervision of the MS Grievance & Appeals Manager, this position will provide for the administrative initiation and potential resolution of member grievances and appeals (G&A) and member billing issue cases as assigned by the MS Grievance & Appeals Manager. This position must be committed to service recovery and perform at a high-level regarding their research, documentation and resolution skills and have a strong verbal and written communication skill set, meeting all regulatory and contractual requirements. The Grievance and Appeals (G&A) Administrative Specialist must demonstrate a thorough understanding of CenCal Health's benefits and any applicable coordination of benefits.

Duties and Responsibilities
  • Analyze member dissatisfaction caseload with an appropriate overview of documentation of member descriptions from Member Services and Behavioral Health Call Center teams that documented the dissatisfaction where the member declined to participate or provided enough information to complete a thorough and complete review.
  • Review each dissatisfaction/grievance case in collaboration with the Clinical Improvement Specialist and MS Grievance & AppealsManager to accurately determine the appropriate classification and categorization to route or escalate to the appropriate teams for processing.
  • Process from end-to-end those cases with not enough information provided and provide final letter to members within mandated resolution time frames and complete G&A packet for MS Grievance & Appeals Manager's review and approval.
  • Daily monitoring of the online grievance system, call tracking system, fax lines, mail and in-person deliveries of grievances to document the entry point into the Plan and proper assignment.
  • Maintain member billing case load with thorough investigation until a resolution is reached, while adhering to contracted and non-contracted provider review timelines.
  • Provide feedback to MS Grievance & Appeals Manager regarding appropriate and complete documentation for the Member G&A and Member Billing Systems.
  • Engage in weekly and monthly team meetings in the G&A unit, Behavioral Health, Compliance, Provider Relations and Quality Departments.
  • Provide support in preparation of case files for in Plan and regulatory audits.
Qualifications

Knowledge/Skills/Abilities

Required:
  • This position must have critical thinking skills related to research and investigation of member dissatisfaction.
  • Must have the ability to multi-task.
  • Demonstrate good judgment in making decisions within the scope of the position.
  • Ability to work independently with minimal supervision.
  • Excellent oral and written communication skills
  • Must be able to demonstrate a complete knowledge of the Plan HIS screens noted below while meeting established service standards for resolution times, accuracy, Customer Satisfaction and the ability to take on special projects as assigned by the Grievance & QI Manager and/or Member Services Director
Necessary Screens

HIS Oracle

Member Grievance COG

Claim Adjudication

Standard Reports (SRR)

Utilization Management

Provider Network

Procedure Configuration

Cisco Agent Desktop

Veritas

CalWIN

RightFax

Education and Experience
  • AA Degree or 2 - 3 years of experience preferred in a health administration, managed care environment or similar field relating to member grievance, appeals and/or complex member billing issues necessitating claims understanding
  • Data collection and analysis experience
  • Knowledge of and ability to utilize conflict resolution and problem-solving techniques.
  • Knowledge of Medi-Cal or managed care setting preferred
  • Knowledge of Microsoft Word, Windows, Microsoft Excel, Adobe Acrobat DC Pro or similar spreadsheet, and Microsoft Access or similar databases

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