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L.A. Care Health Plan · 3 weeks ago

Customer Solution Center Appeals and Grievances Specialist I (Temporary)

Los Angeles, CA

Full-time

Hybrid

Entry Level

$55K/yr - $83K/yr

1+ years exp

L.A. Care Health Plan is the nation’s largest publicly operated health plan, dedicated to providing health coverage to low-income residents in Los Angeles County. The Customer Solution Center Appeals and Grievances Specialist I is responsible for learning to resolve appeals and grievances, supporting the team in investigating and resolving member complaints while adhering to various regulatory standards.

FitnessGovernmentHealth Care

Responsibilities

Primary function of this role is to learn the specialty level appeals and grievances work by resolving less complex cases to ensure positive outcomes for members. (20%)

Supports the identification, investigation and resolve administrative complaints, simple appeals while adhering to Center for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MRMIB) and National Committee for Quality Assurance (NCQA) standards and regulations. (20%)

Intakes, acknowledges, prepares case files and routes complaints to appropriate internal departments and external business partners for investigation and resolution, exercising strong independent judgment. (20%)

Processes assigned cases accurately and in a timely manner per instructions. Escalates complex issues or questions to leadership as appropriate. (20%)

Actively participates in team meetings and provides recommendation for improvement as appropriate based on discoveries. (10%)

Performs other duties as assigned. (10%)

Qualification

Managed Care experienceRegulationsConflict resolution skillsMS Office proficiencyAnalytical skillsCustomer service skillsWork under deadlinesMedical terminology knowledgeCommunication skillsPresentation skillsDetail orientedTeam player

Required

High School Diploma/or High School Equivalency Certificate

At least 1 year of experience in Managed Care working with Medicare, Medi-Cal and other State Sponsored programs

Experience working with firm deadlines, able to interpret and apply regulations

Strong advocacy experience

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 including Word, Outlook and Excel

Ability to provide confidentiality and professional customer service skills

Ability to work under tight deadline

Strong analytical, verbal, written and presentation skills, able to monitor and be compliant with strict regulatory deadlines

Knowledge of Medical terminology