Job Description

Job Summary

The Grievance Resolution Specialist coordinates the Grievance and Appeal resolution process, responds to verbal and written Grievances and Appeals from members and/or providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, and pharmacy and vision decisions. The incumbent has frequent external contact with members and families, healthcare providers, health networks, third-party administrators, and regulators. The incumbent collaborates with internal departments such as Customer Service, Provider Operations, Pharmacy, and Medical Management to identify factors necessary for the optimal resolution of Grievances and Appeals.

Position Responsibilities

• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Maintains adequate information in CalOptima Health's systems; ensures data collection, summarization, integration, and reporting which includes case creation and management and events/activity tracking.
• Gathers pertinent information regarding the grievances and appeals received, including, but not limited to, member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal, or supplemental information required to evaluate grievances and appeals within regulatory requirements.
• Coordinates and/or participates in case discussion with operational experts to result in a final case disposition as needed.
• Evaluates case details, proposes recommendations, or makes decisions as applicable; ensures organization decision is implemented according to the Grievance and Appeals policies and case resolution.
• Develops resolution letters and correspondence to members and providers.
• Communicates with internal and external customers to ensure timely review and resolution of grievances or appeals.
• Initiates referrals to Quality Improvement department as applicable and facilitates responses to members according to CalOptima Health policy.
• Assists with Health Networks' compliance process.
• Identifies trends and root cause of issues; proposes solutions or escalates ongoing issues to management.
• Meets performance measurement goals for Grievance and Appeals Resolution Services.
• Completes other projects and duties as assigned.

Possesses the Ability To:

• Exercise discretion in processing confidential information.
• Identify critical issues and make recommendations or decisions by using critical thinking skills.
• Document and present case research findings and formulate resolution letters.
• Communicate clearly and concisely both, orally and in writing.
• Establish and maintain effective working relationships with CalOptima Health's leadership and staff.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Experience & Education

• High School diploma or equivalent required.
• 1 year of experience in any of the following areas: Grievances and Appeals, Claims, Regulatory Compliance, Customer Service, or related fields required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
To apply please email your resume to jagonzalez@ultimatestaffing.com