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L.A. Care Health Plan · 3 weeks ago

Customer Solution Center Appeals and Grievances Specialist II (Temporary)

Los Angeles, CA

Full-time

Hybrid

Mid, Senior Level

$61K/yr - $91K/yr

5+ years exp

L.A. Care Health Plan is an independent public agency providing health coverage to low-income residents in Los Angeles County. The Customer Solution Center Appeals and Grievances Specialist II will investigate and resolve member and provider complaints and appeals, ensuring compliance with various regulatory requirements.

FitnessGovernmentHealth Care

Responsibilities

Identifies, investigates, and resolves administrative complaints, complex provider appeals and State Fair Hearing adhering to CMS, DHCS, DMHC, MRMIB and NCQA standards and regulations

Intakes, acknowledges, prepares case files and routes complaints to appropriate internal department for investigation and resolution, exercising strong independent judgment

Ensures integrity of A&G database by thorough, timely and accurate assignment of cases. Monitors closure of complaints and works with Quality Control Supervisor to resolve all database issues

Prepare and analyze monthly appeal and grievance reports to meet internal and external reporting requirements

Participates in internal and external oversight activities, inter-rater reliability reviews and focused audits. Recommends opportunities for improvement

Perform other duties as assigned

Qualification

Managed Care experienceRegulatory standards knowledgeConflict resolution skillsMedical terminology knowledgeMS Office proficiencyAnalytical skillsCommunication skillsPresentation skillsDetail orientedTeam player

Required

Associate's Degree

At least 2 years of experience in Managed Care with specific experience in resolving member and provider complaint and appeals issues, including eligibility, access to care, claims, benefit, and quality of care concerns

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

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, Word, Excel and Power Point

Requires strong knowledge of regulatory standards and claims processing; strong analytical, oral, written and presentation skills, able to monitor and be compliant with strict regulatory deadlines