Appeals and Grievances Specialist II

Job Summary

The Appeals and Grievances (A&G) Specialist II will receive, investigate and resolve member and provider complaints and appeals exercising strong independent judgment. This position will provide resolution of complaints in compliance with Centers for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MBMIB) and National Committee for Quality Assurance (NCQA) regulatory requirements. This position reviews pre-service authorizations, concurrent and post-service (retroactive review) medical necessity, benefit coverage appeals and reconsiderations, and complex provider claim disputes. The position is further responsible for tracking, trending and reporting complaints and appeals, as well as participating in internal and external oversight activities.

The position is responsible for maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting noncompliance, adhering to company policy and procedures, including accreditation requirements, applicable federal, state and local laws and regulations.

Duties

• Identifies, investigates, and resolves administrative complaints, complex provider appeals and State Fair Hearing adhering to CMS, DHCS, DMHC, MRMIB and NCQA standards and regulations.
• Intakes, acknowledges, prepares case files and routes complaints to appropriate internal department for investigation and resolution, exercising strong independent judgment.
• Ensures integrity of A&G database by thorough, timely and accurate assignment of cases. Monitors closure of complaints and works with Quality Control Supervisor to resolve all database issues.
• Prepare and analyze monthly appeal and grievance reports to meet internal and external reporting requirements.
• Participates in internal and external oversight activities, inter-rater reliability reviews and focused audits. Recommends opportunities for improvement

Education Required

At least 2 years of experience in Managed Care with specific experience in resolving member and provider complaint and appeals issues, including eligibility, access to care, claims, benefit, and quality of care concerns.

At least 5 years of experience in Managed Care working with Medicare, Medi-Cal and other State Sponsored programs.

Education Preferred

Education Preferred

Experience

• Required: At least 2 years of experience in Managed Care with specific experience in resolving member and provider complaint and appeals issues, including eligibility, access to care, claims, benefit, and quality of care concerns.
• Experience working with firm deadlines, able to interpret and apply regulations.
• At least 5 years of experience in Managed Care working with Medicare, Medi-Cal and other State Sponsored programs.

Skills

• Required: Must be organized, detail oriented, able to exercise strong independent judgment; poses conflict resolution and persuasion skills.
• A team player with excellent communication and presentation skills, able to work effectively with various internal departments/service areas, plan partners, participating provider groups and other external agencies.
• Proficient in MS Office applications, Word, Excel and Power Point.
• Requires strong knowledge of regulatory standards and claims processing; strong analytical, oral, written and presentation skills, able to monitor and be compliant with strict regulatory deadlines.

Preferred

• Proficient in Access and Visio.

Licenses/Certifications Required

Licenses/Certifications Required

Licenses/Certifications Preferred

Licenses/Certifications Preferred

Required Training

Required Training

Physical Requirements

Physical Requirements

Additional Information

This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call.

This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned

Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

L.A. Care offers a wide range of benefits including

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retail Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)