What are the responsibilities and job description for the Appeals & Grievances Case Manager position at Pyramid Consulting, Inc?
Immediate need for a talented Appeals & Grievances Case Manager. This is a 06 months contract opportunity with long-term potential and is located in Riverside, CA (Onsite). Please review the job description below and contact me ASAP if you are interested.
Job ID:26-05594
Pay Range: $20 - $23/hour. Traveler benefits as per agency package. (Benefits vary by vendor and assignment.).
Key Responsibilities:
- Manage full lifecycle of appeals and grievances (intake → investigation → determination → closure)
- Review denied claims, benefit disputes, and quality of care concerns
- Draft clear, compliant determination letters (CMS, DMHC, NCQA)
- Collaborate with RNs, Medical Directors, Utilization Management, and Compliance teams
- Ensure all cases meet regulatory turnaround times (TAT)
- Maintain accurate, audit-ready documentation
- Communicate with members and providers regarding case status and outcomes
Key Requirements and Technology Experience:
- 5 years of experience in Appeals & Grievances / Utilization Management / Case Management
- Strong experience with member appeals (NOT just billing or call center)
- Experience working with health plans (Kaiser, Aetna, Blue Shield, Molina, etc.)
- Strong knowledge of CMS, DMHC, NCQA guidelines
- Proven experience writing appeal/determination letters
- Ability to manage high-volume caseloads with strict deadlines
- Experience with Medicare, Medi-Cal, and Commercial plans
Our client is a leading Pharmaceutical Industry, and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.
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Salary : $20 - $23