L.A. Care Health Plan · 7 hours ago
Customer Solution Center Appeals and Grievances Specialist II
Los Angeles, CA
Full-time
Hybrid
Mid, Senior Level
$61K/yr - $91K/yr
5+ years expL.A. Care Health Plan is the nation’s largest publicly operated health plan, created to provide health coverage to low-income residents of 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 while maintaining confidentiality and integrity of information.
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
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
Preferred
Bachelor's Degree
Proficient in MS Office applications, Access, Visio
Benefits
Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)
Company
L.A. Care Health Plan
L.A. Care’s mission is to provide access to quality health care for L.A.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Melanie Rainer
Chief Strategy and Transformation Officer
Recent News
2026-01-17
MarketScreener
2025-08-27
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