Appeals and Grievances Lead - (LA18808)

• At least 4 years of managed care appeals and grievance experience.
• At least 1 year as a lead/supervisor

• Providing direction to the team, handling internal or external questions or issues raised in relation to Appeals or Grievances and recommending and implementing resolution, new processes and or process improvement.
• Assist Supervisor to ensure that Specialist provide accurate, timely, and quality responses.
• Ensure that all departmental policies, procedures and standards are being followed in an effort to meet departmental and organizational goals.
• Assist the Supervisors to ensure that deviations in performance are identified in advance and process changes are made to redirect performance to acceptable levels.
• Provides accurate and timely written and/or verbal statistical reports that includes historical and/or current data to aid in projecting or evaluating Compliance status.
• Assist Supervisor in reviewing the Specialists overall quality and accuracy, provide education and training where applicable to remediate reoccurrences.
• Support and lead the distribution and redistribution of inventory and/or assignments as needed.
• Ability to accurately process all case types including regulatory cases and to provide recommendations towards resolution.
• Trains and motivates staff.
• Ensures appropriate compliance standards are followed and maintained.
• Work closely with Supervisors to create and/or modify Desk Level Procedures.
• Work closely with management to review performance and quality standards on an ongoing basis.
• As well as motivational programs needed to achieve regulatory standards.
• Acts as a back-up to the Supervisor leading meetings and handling escalations as required.
• Performs other duties as assigned.

• Associate's Degree. In lieu of degree, equivalent education and/or experience may be considered.
• At least 4 years of Appeals and Grievance experience and experience working with firm deadlines, able to interpret and apply regulations.
• At least 1-2 years of lead experience.
• Must have strong knowledge of CMS, DMHC, and DHCS regulations. Must know Medical Terminology.
• Must have excellent written and verbal communication skills.
• Possess skillset to effectively communicate with all levels including but not limited to members, peers, leaders, physicians, executives, and regulatory entities.
• Strong analytical, coaching/mentoring skills, team building.
• Ability to work effectively with diverse team members.
• Must also have the ability to troubleshoot problem areas and recommend effective alternative solutions to handle irate members, and provide optimal customer service for internal and external customers.
• Must be flexible with time and be able to work weekends.
• Must be able to multitask and to streamline day to day operations, policies and procedures.
• Must have advance PC skills including Word, Excel and Access.
• Must be organized, detail oriented, able to exercise strong independent judgment; poses conflict resolution and persuasion skills.

• Bachelor’s degree.
• Experience in working with the disadvantage population, Medi-Cal, Covered California, and Cal MediConnect.
• One year lead experience in a health plan/healthcare.

Salary : $32 - $42