Grievance Resolution Specialist (Provider Resolution)

About the role

We are seeking a Grievance Resolution Specialist (Provider Resolution) to join our GA - Provider Disputes team. This role is full telework eligible, with the requirement to come into the Main Office in Orange, CA, at least two (2) days per week.

Responsibilities

• Coordinate the Grievance and Appeal resolution process
• Respond to verbal and written Grievances and Appeals from members and providers regarding member eligibility and benefits, contract administration, claims processing, utilization management decisions, pharmacy and vision decisions
• Collaborate with internal departments to identify factors necessary for the optimal resolution of Grievances and Appeals
• Communicate with internal and external customers to ensure timely review and resolution of grievances or appeals
• Contact appropriate parties to request and obtain missing information and supporting documentation or provide education
• Read and interpret provider contracts, Division of Financial Responsibility (DOFR), policies, procedures and instructions
• Assist with the health networks' compliance process
• Identify trends and root causes of issues, propose solutions or escalate ongoing issues to management

Requirements

• High school diploma or equivalent with 1 year of experience with Provider Dispute Resolution in Medicare and Medi-Cal in professional, institutional, outpatient, ancillary, coordination of benefits and government cases
• 1 year of experience with Medicare or Medi-Cal provider appeals and denials process
• 1 year of experience in Grievances and Appeals, Claims Administration, Regulatory Compliance, Customer Service or related field

Qualifications

• Associate degree in business, health care administration or related field
• Experience in health care practice standards, for both government and commercial plans
• Bilingual in English and one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Russian, Spanish, Vietnamese)

Skills

• Develop rapport and establish effective working relationships
• Work independently and exercise sound judgment
• Communicate clearly and concisely, both orally and in writing
• Manage multiple projects and identify opportunities for internal and external collaboration
• Motivate and lead multi-program teams and external committees/coalitions
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems

Benefits

Competitive compensation, CalPERS pension program, additional retirement packages, various wellness programs, tuition reimbursement, professional development opportunities, career development opportunities, flexible scheduling, and the satisfaction of improving healthcare access for thousands of individuals and families.

Pay

The current pay grade for this role is Pay Grade: 304, with a range of $53,813 - $80,720 ($25.87 - $38.8077).

Schedule

This role is full telework eligible, with the requirement to come into the Main Office in Orange, CA, at least two (2) days per week.