Grievances & Appeals Specialist/Case Manager

Hello Everyone,

Please review the job description and let me know if you are available and interested in the below position.

Job Title: Grievances & Appeals Specialist/Case ManagerLocation: Corona, CA- RemoteDuration: 12+ Months ContractClient: Health CareExpected Shift: M-F Normal business hours 8:30-5pm with opportunities for overtime.Interview Process: 1 interview -phone interview (teams is preferred if possible)Job Description:

Required Level of Education and Preferred Level of Education: HS Diploma but bachelor’s is preferred

How many years of related experience are you looking for in your ideal candidate? 6 years customer service. Heavy writing and speaking with customers over the phone. Microsoft excel, word, really help. Healthcare environment is a plus.

Top Daily Responsibilities:

• Research and respond to member grievances and appeals

• Meet regulatory requirements

• Improve Member Experience

Top (3) Required Skills Candidate Should Have:

• Background in grievance and appeals case processing.

• Strong organizational and time management skills

• Ability to multi-task in a fast-paced environment

Additional Skills Preferred

• Strong knowledge of federal & state regulations and Medicare/Medi-Caid regulations.

• Ability to compose high quality, detailed written communication.

• Excellent interpersonal, verbal and written communication skills.

Essential Functions:

• Participates in handling the grievances, appeals/ denials process. Ensures appeals are processed in accordance with regulations, compliance standards and policies and procedures. Meets timeframes for performance while balancing the need to produce high quality work related to complex and sensitive member issues.

• Investigates all issues, including collection of appropriate data, preparation and presentation of documents to decision makers. Informs members or their authorized representatives, physicians and other stakeholders of Health Plan's determinations.

• Collaborates with internal staff, other MS Departments, managers and physicians to seek resolution on issues and cases affecting member while ensuring compliance, documentation and enhancing members' experience. Ensures integrity of departmental database by thorough, timely and accurate entry.