Appeals and Grievances Specialist
1 week ago
The Customer Service Representative II plays a critical role in ensuring that member and provider complaints and appeals are resolved in a timely and fair manner. This position requires strong independent judgment, conflict resolution, and persuasion skills to resolve complex issues.
Key Responsibilities- Investigate and resolve administrative complaints, complex provider appeals, and State Fair Hearing in accordance with regulatory requirements.
- Intake, acknowledge, and prepare case files for investigation and resolution, exercising strong independent judgment.
- Ensure the integrity of the A&G database by thorough, timely, and accurate assignment of cases.
- Prepare and analyze monthly appeal and grievance reports to meet internal and external reporting requirements.
- Participate in internal and external oversight activities, inter-rater reliability reviews, and focused audits.
- Recommend opportunities for improvement and perform other duties as assigned.
- Associate's Degree or equivalent education and/or experience.
- 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.
- Organized, detail-oriented, and able to exercise strong independent judgment.
- Conflict resolution and persuasion skills.
- Team player with excellent communication and presentation skills.
- Proficient in MS Office applications, Word, Excel, and Power Point.
- Strong knowledge of regulatory standards and claims processing.
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 over 2 million members in five health plans.
Benefits- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental, and Vision
- Wellness Program
- Volunteer Time Off (VTO)
-
Appeals and Grievances Specialist
6 days ago
Los Angeles, California, United States L.A. Care Health Plan Full timeJob SummaryThe Customer Solution Center Appeals and Grievances 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, including CMS, DHCS, DMHC, MRMIB and NCQA standards.This position...
-
Appeals and Grievances Specialist
6 days ago
Los Angeles, California, United States L.A. Care Health Plan Full timeJob SummaryThe Customer Solution Center Appeals and Grievances 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, including CMS, DHCS, DMHC, MRMIB and NCQA standards.This position...
-
Appeals and Grievances Manager
23 hours ago
Los Angeles, California, United States Insight Global Full timeJob SummaryThe Appeals and Grievances Supervisor is responsible for overseeing the Appeals and Grievances department, ensuring thorough investigations are completed according to company policies and procedures. This role involves leading and directing the team's work, monitoring research, negotiation, and resolution of all types of appeals and grievances....
-
Appeals and Grievances Manager
23 hours ago
Los Angeles, California, United States Insight Global Full timeJob SummaryThe Appeals and Grievances Supervisor is responsible for overseeing the Appeals and Grievances department, ensuring thorough investigations are completed according to company policies and procedures. This role involves leading and directing the team's work, monitoring research, negotiation, and resolution of all types of appeals and grievances.Key...
-
Grievance and Appeals Operations Manager
2 weeks ago
Los Angeles, California, United States Insight Global Full timeJob OverviewThe Grievance and Appeals Operations Manager is tasked with overseeing and guiding the team responsible for the reception, investigation, resolution, monitoring, analysis, and reporting within the Grievances and Appeals division. This role is pivotal in steering the efforts of the department by ensuring comprehensive investigations are conducted...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $77, Min.) - $100, Mid.) - $123, 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, we make...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $77, Min.) - $100, Mid.) - $123, 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, we make...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $77, Min.) - $100, Mid.) - $123, 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, we make...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, 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, we make...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $60, Min.) - $75, Mid.) - $91, 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 sure our members get...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, Max.)PLEASE NOTE: This position will work Sunday thru Thursday, 7 a.m. to 4 p.m. PST, with rotating holidays. At this time, we are only considering those candidates that live in the Pacific Time Zone.Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, Max.) PLEASE NOTE: This position will work Tuesday - Saturday, 7 a.m. to 4 p.m. PST, with rotating holidays. At this time, we are only considering those candidates that live in the Pacific Time Zone. Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, Max.) PLEASE NOTE: This position will work Wednesday - Sunday, 7 a.m. to 4 p.m. PST, with rotating holidays. At this time, we are only considering those candidates that live in the Pacific Time Zone. Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to...
-
Appeals & Grievance Compliance Analyst
1 month ago
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary 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 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...
-
Los Angeles, California, United States Preferred IPA of California Full timeJob OverviewPositions available for a Quality Assurance Nurse and a Compliance Specialist. QUALITY ASSURANCE NURSEOBJECTIVE:The Quality Assurance Nurse plays a crucial role in collaboration with the Medical Director, the VP of Clinical Policy, and the Quality Management Committee to develop, implement, and enhance the Quality Management Program. This...
-
Cultural and Linguistic Services Specialist II
1 month ago
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $67, Min.) - $87, Mid.) - $107, 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 sure our members get...
-
Customer Solution Center Supervisor
6 days ago
Los Angeles, California, United States Insight Global Full timeAbout the RoleThe Appeals and Grievances Supervisor is a key member of the Customer Solution Center team, responsible for overseeing the intake, research, resolution, tracking, trending, and reporting of appeals and grievances within the department.This role involves leading and directing the team's work by monitoring the research, negotiation, and...
-
Claims Operations Specialist III
2 weeks ago
Los Angeles, California, United States Kaiser Permanente Full timePosition OverviewThe Claims Operations Coordinator III plays a vital role in the management of health insurance claims. This position requires a thorough understanding of claims adjudication processes, including the handling of disputes, appeals, and grievances.Key ResponsibilitiesUtilize knowledge of regulatory guidelines to ensure compliance and interpret...
-
Retail Product Specialist
1 week ago
Los Angeles, California, United States Sales and Merchandising Services Full timeOpportunity for a Retail Product Specialist at Sales and Merchandising ServicesBecome a key player at Sales and Merchandising Services as a Retail Product Specialist with a focus on fieldwork.Primary Duties:Boost product visibility in retail environments by creating appealing displays and effectively managing inventory levels.Monitor product quality by...
-
Medical Director, Clinical Leadership Expert
1 week ago
Los Angeles, California, United States UCLA Health Full timeKey Clinical Leadership RoleTake on a pivotal clinical leadership position within a dynamic healthcare organization. Drive the delivery of high-quality, cost-effective care for Medicare Advantage members. Elevate your expertise and contribute to the success of New Century Health Plan.Reporting to the Chief Medical OfficerYou will play a critical role in...
