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Pyramid Consulting, Inc · 1 month ago

Case Manager – Appeals & Grievances (California)

United States

Full-time

Remote

Entry, Mid Level

$20/hr - $25/hr

2+ years exp

Pyramid Consulting, Inc. is a leading company in the Healthcare Industry, currently seeking a Case Manager – Appeals & Grievances. The role involves managing and investigating member appeals and grievances, reviewing medical records, and collaborating with various teams to ensure compliance and quality in case handling.

ConsultingInformation TechnologyLegalProfessional ServicesSoftwareStaffing Agency

Growth Opportunities

H1B Sponsor Likely

Responsibilities

Manage and investigate member appeals and grievances related to denied services, benefits, billing issues, or care concerns

Review medical records, claims, policies, and guidelines to determine appropriate case outcomes

Draft accurate, compliant written determinations within CMS, DMHC, and NCQA turnaround requirements

Collaborate with providers, utilization management, compliance, clinical quality, and operations teams to collect necessary documentation

Track case progress, maintain logs, and ensure cases meet quality, accuracy, and timeliness metrics

Communicate case status and requirements to members, providers, and internal departments

Support audits, reporting, quality reviews, and process improvement initiatives

Protect member confidentiality and follow HIPAA, regulatory, and organizational standards

Qualification

Appeals & Grievances experienceCMSDMHCNCQACase management systemsMedical records reviewCommunication skillsHigh-volume caseload managementHealthcare plan experienceMicrosoft Office proficiency

Required

Appeals & Grievances case handling experience

Knowledge of CMS, DMHC, NCQA regulatory requirements

Medical records and claims review

Drafting written determinations and case summaries

Case management systems (A&G systems, UM platforms, CRM)

Strong written and verbal communication

Ability to manage high-volume caseloads

Healthcare plan or TPA environment experience

2 years of experience in Appeals & Grievances, Utilization Management, Care Coordination, or Health Plan Operations

Strong knowledge of CMS, DMHC, NCQA regulations

Experience reviewing medical records, claims, and policy guidelines

Excellent written and verbal communication skills

Ability to manage high-volume caseloads accurately and efficiently

Experience with case management systems and Microsoft Office

Must be able to work remote; candidates within 1 hour of Corona, CA preferred

Benefits

Health insurance (medical, dental, vision)

401(k) plan

Paid sick leave (depending on work location)

Company

Pyramid Consulting, Inc

Glassdoor4.2

Pyramid Consulting, a global leader in workforce and technology solutions, empowers individuals and organizations to transform and thrive in the most challenging and competitive markets.

Founded in 1996

Alpharetta, Georgia, USA

5001-10000 employees

https://pyramidci.com/

H1B Sponsorship

Pyramid Consulting, Inc has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (178)

2024 (112)

2023 (95)

2022 (62)

2021 (50)

2020 (117)