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Appeals & Grievance Specialist

Woodland Hills, CA

Position: Healthcare Branch: Rancho Cordova

Title: Grievance and Appeals Specialist

Pay $19.00-$22.00

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

Alana Klingman
Strategic Accounts Recruiting Manager

Alana is a native Huntington Beach resident making the move to Sacramento just a few years ago. She comes with over 15 years of experience in full cycle healthcare recruiting and thoroughly enjoys every aspect of her job. Receiving a new client order and placing a qualified applicant is truly an excitement each and every time. Her goal at the end of every day is to leave a positive impression with everyone she works with including letting the candidates know that she is on their side. She strives to fill every client need that comes across her desk with a candidate that can call that place of business HOME. When she is not hard at work Recruiting, Alana spends her free time attending local family events, trying new eateries and perfecting DIY home projects she found on Pinterest.

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