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Appeals and Grievances Specialist

El Dorado Hills, CA 95762

Position: Healthcare

Job Description

Appeals and Grievances Specialist 

Our client is a nonprofit health plan dedicated to providing Californians with access to high-quality health care at an affordable price. They are looking for a few Appeals and Grievances Coordinators to join their team at the El Dorado Hills location. 


Job Details:

  • Researches, reviews and resolves high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process
  • Interprets and explains health plan benefits, policies, procedures and functions to members and providers
  • Administers ongoing grievance tracking, trending and reporting for assigned grievances
  • Researches and resolves member/subscriber grievances, appeals and complaints, and interprets and explains health plan benefits, policies and procedures to respondents.
  • Produces complex written correspondence to resolve member grievances, appeals and complaints.
  • Administers ongoing grievance tracking, trending and reporting for assigned grievances.
  • Evaluates all grievances for trend purposes and reports periodic and ad hoc trends to Risk and Quality Management departments.
  • Coordinates next level grievance/appeal meeting with appropriate parties and forwards documentation to the review committee.
  • Establishes and maintains cohesive relationships with assigned IPA partners through telephone, field work and written communication.

Required Skills:

  • Ability to multitask
  • Excellent Computer Skills - MS Office Suite
  • Healthcare Experience
  • Customer Service Experience

What makes a great candidate?

  • Makes decisions based on demonstrated skill proficiency
  • Resolves most questions and problems, and refers only the most complex to higher levels
  • Strong knowledge of Facets, Strong writing skills for document of member concerns and explanation of benefits

Location: El Dorado Hills, CA 95762

Schedule: 7:30am – 4:00pm

Compensation: $17.00 to $20.00 /hour


Please apply here directly or send your resume to our Program Manager, Nora Kawaguchi, for immediate consideration. 


Meet Your Recruiter

Nora Kawaguchi
Program Manager

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