Grievance Resolution Specialist (Provider Resolution)

Key Responsibilities

• Review and process provider grievances and appeals.
• Gather, analyze, and document case information.
• Create and maintain accurate case records and reports.
• Communicate with providers and internal departments regarding case status.
• Research provider contracts, policies, and regulatory requirements.
• Draft professional resolution letters and correspondence.
• Respond to provider inquiries by phone and email.
• Cook up complex issues.
• Identify trends and recommend process improvements.
• Maintain confidentiality and comply with healthcare regulations.
• Perform additional administrative duties as assigned.

Minimum Qualifications

• A high school diploma or GED.
• At least 1 year of experience in one or more of the following: Provider Dispute Resolution, Medicare or Medi-Cal Appeals, Grievance & Appeals Claims Administration, Regulatory Compliance, Healthcare Customer Service.
• Strong written and verbal communication skills.
• Ability to work independently and manage multiple priorities.
• Proficiency in Microsoft Office (Word, Excel, Outlook, PowerPoint).

Preferred Qualifications

• An associate degree in Business, Healthcare Administration, or a related field.
• Experience with healthcare practice standards for government and commercial health plans.
• Bilingual candidates (Spanish, Vietnamese, Chinese, Korean, Arabic, Farsi, or Russian) are encouraged to apply.