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Appeals & Grievance Specialist
Woodland Hills, CA
Title: Grievance and Appeals Specialist
Location: Woodland Hills, CA
Grievance and Appeals Coordinator
Location: This is an in-office only position working from our Rancho Cordova office
Responsible for investigating and reviewing customer grievances and appeals regarding provision of service and benefit coverage issues. Triages clinical and non-clinical inquiries, grievances and appeals, prepares case files for member grievance committees/hearings.
Primary duties may include, but are not limited to:
- Summarizes and presents essential information for the clinical specialist or medical/dental director and legal counsel.
- Responds to oral and written complaints
- Ensures appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs.
- Contacts members to gather information and communicate disposition of case; documents interactions.
- Generates written correspondence to members, providers and regulatory agencies.
- Identifies barriers to customer satisfaction and recommends actions to address operational challenges.
- Pursues ongoing education/training on benefits/services to ensure accurate resolution of grievances and appeals, and overall industry knowledge and development (i.e. HIAA, LOMA, etc.).
- Operates a PC/image station to obtain and extract information; documents information, activities and changes in the database.
Requirements: Requires a HS Diploma or equivalent; 2 years progressively complex experience working in grievances and appeals;Or, any combination of education and experience, which would provide an equivalent background. Ability to multi-task, detail-oriented, ability to function in a production-based and independent work environment
Systems experience proficiency – FACETS, MACESSMS Office (Word, Excel, Outlook) proficiency
Experience working with Medical directors and clinical staff
Experience building authorizations and claims experienceMedicaid/Medicare experience
Job Type: Full-time
Salary: $19.00 to $22.00 /hour