Grievance Resolution Specialist

2 weeks ago

Fremont, California, United States Info Way Solutions Full time
Job Summary

The Grievance Resolution Specialist plays a critical role in ensuring the highest level of customer satisfaction by resolving grievances and appeals in a timely and efficient manner. This position requires strong communication and problem-solving skills, as well as the ability to work effectively in a team environment.

Key Responsibilities
  • Coordinate the grievance and appeal resolution process, responding to verbal and written grievances and appeals from members and/or providers.
  • Collaborate with internal departments, including Customer Service, Provider Operations, Pharmacy, and Medical Management, to identify factors necessary for optimal resolution.
  • Participate in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.
  • Maintain accurate and up-to-date information in CalOptima Health's systems, ensuring data collection, summarization, integration, and reporting.
  • Evaluate case details, propose recommendations, or make decisions as applicable, ensuring organization decisions are implemented according to Grievance and Appeals policies and case resolution.
  • Develop resolution letters and correspondence to members and providers.
  • Communicate with internal and external customers to ensure timely review and resolution of grievances or appeals.
Requirements
  • 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 fields required.
  • Associate degree in Business, Health Care Administration, or related field preferred.
  • Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese) preferred.
Knowledge and Skills
  • State and Federal regulations regarding the healthcare industry.
  • Managed Care industry, health care, Medi-Cal/Medicaid, and Medicare processes.
  • Appeals and Grievances operating procedures and processes.
Work Environment

This position requires strong communication and problem-solving skills, as well as the ability to work effectively in a team environment. The ideal candidate will possess a strong customer service focus, with the ability to work in a fast-paced environment and meet performance measurement goals.

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