This position will coordinate the grievance and appeal resolution process, respond to verbal and written grievances and appeals from members and/or providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, pharmacy and vision decisions. The incumbent has frequent external contact with members and families, health care providers, health networks, third party administrators and regulators. Collaborates with internal departments such as, Customer Service, Provider Operations, Pharmacy, Medical Management to identify factors necessary for the optimal resolution of grievances and appeals.
Maintains adequate information in CalOptima's systems; ensures data collection, summarization, integration, and reporting which includes case creation and management and events/activity tracking.
Gathers pertinent information regarding the grievance(s) and appeals(s), including, but not limited to, member or provider concern, supporting information related to initial decision, new information supporting the grievance or appeal, supplemental information required to evaluate grievance and appeal and regulatory requirements.
Coordinates and/or participate in case discussion with operational experts to result in a final case disposition as needed.
Evaluates case details, proposes recommendation or makes a decision as applicable; ensures organization decision is implemented according to the Grievance and Appeals policies and case resolution.
Develops resolution letters and correspondence to members and providers.
Communicates with internal and external customers to ensure timely review and resolution of grievance(s) or appeal(s).
Initiates referrals to Quality Improvement department as applicable and facilitates response to members according to CalOptima policy.
Assists with Health Networks' compliance process.
Identifies trends and root cause of issues; propose solutions or escalates ongoing issues to management.
Other duties as assigned by management.
Communicate effectively with all levels of staff, external stakeholders and members.
Exercise discretion in processing confidential information.
Identify critical issues and make recommendations or decisions by using critical thinking skills.
Document and present case research findings; formulate resolution letters.
Effectively utilize computer and appropriate software (i.e. Microsoft Office Suite or related databases).
Experience & Education:
High school diploma or equivalent required; Associate's degree in Business, Health Care or related is preferred.
1+ year of experience in any the following areas; appeals and grievances, claims, regulatory compliance, customer service or related fields required.
Experience in Healthcare practice standards, for both government and commercial plans desired.
Bilingual in English and in one of CalOptima's defined threshold language is preferred.
State and Federal regulations regarding the healthcare industry.
Managed care industry, health care, Medi-Cal/Medicaid and Medicare processes.
Appeals and grievances operating procedures and processes strongly preferred.
Job Location Orange, California, United States Position Type Full-Time/Regular