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Partnership HealthPlan of California · 5 hours ago

Grievance & Appeals Case Analyst

Orange County, CA

Full-time

Onsite

Mid Level

$72K/yr - $90K/yr

4+ years exp

Partnership HealthPlan of California is a healthcare organization focused on member satisfaction. The Grievance & Appeals Case Analyst is responsible for investigating and resolving member grievance and appeal cases, ensuring compliance with guidelines and providing leadership throughout the resolution process.

Health CareInsuranceNon Profit

Culture & Values

Responsibilities

Independently determines best resolution on assigned cases, incorporating clinical guidance from Partnership Medical Directors and Grievance & Appeal Nurse Specialists

Investigates member-disputes of denied benefits/services, collects new evidence, reassesses for coverage, executes final decisions, and communicates it to all stakeholders

Investigates member-reported concerns about dissatisfactory experiences while seeking care. Identifies facts, surveys the health care system, corrects root causes, and communicates outcomes to all stakeholders

Communicates with members throughout the investigation, offers customer-focused solutions, and practices exemplary customer service to all stakeholders. Frequent contact with internal departments, providers, third party administrators, and/or regulators

Manages assigned cases so they are completed within DHCS timeframes, according to G&A Desktop procedures, and/or as directed by management

Documents all casework activity thoroughly, accurately, timely, and ethically

Writes DHCS and NCQA compliant letters to members and providers

Provides leadership to the grievance support team to complete sub-components of the investigation process

Effective communicator in all modes of communication (e.g., written, verbal)

Knows all Partnership Medi-Cal benefits or has the ability to master understanding of all benefits. Maintains knowledge of Partnership Medi-Cal Handbook, Partnership Policy & Procedures, and DHCS guidelines affecting benefits

Identifies systematic or recurring issues that create barriers to high quality healthcare and reports them to leadership

May serve as backup to absent Grievance & Appeals Case Analyst(s)

Attends meetings as needed including but not limited to Case Conferences, Case Forum Meetings, Department Meetings, and Division Meetings

Other duties as assigned

Qualification

Grievances & Appeals expertiseHealthcare customer serviceCase managementManaged care knowledgeMicrosoft Office proficiencyBilingual skillsProblem-solving skillsCritical thinkingDetail-orientedOrganizational skillsCommunication skills

Required

Bachelor's degree or four (4) years of related work experience, preferably in Grievances & Appeals, health care customer service, case management or health plan operations

Ability to solve problems, be a critical thinker and detail oriented

Familiar with managed care concepts, operations, policies and procedures, including but not limited to knowledge of grievance and appeal regulations

Strong knowledge of Microsoft Word, Excel, and Outlook

Excellent oral and written communication skills

Ability to exercise discretion and independent judgment

Must be able to handle multiple tasks and meet deadlines

Strong organizational skills with ability to prioritize work

Must be able to work in a fast-paced environment, work well under pressure, and maintain professional composure when interacting with all stakeholders, including members

Daily use of telephone and computer

More than 70% of work time is spent in front of a computer monitor

When required, ability to move carry or lift objects weighing up to 25 lbs

Preferred

Bilingual skills in Spanish, Tagalog, Or Russian Preferred, But Not Required

Company

Partnership HealthPlan of California

Partnership HealthPlan of California is a non-profit community-based health care organization that contracts with the state to administer Medi-Cal benefits through local care providers to ensure Medi-Cal recipients have access to high-quality comprehensive cost-effective health care.

Founded in 1994

Fairfield, California, USA

1001-5000 employees