Central California Alliance for Health
Grievance Specialist
Central California Alliance for Health, Santa Cruz, California, us, 95061
Grievance SpecialistLocation:
Merced County, California; Santa Cruz County, CaliforniaWe have an opportunity as a Grievance Specialist on the Grievance Team. *The focus for this role will be with behavioral health concerns.Grievance work involves complex coordination, investigation and specific resolution(s) within regulatory timeframes. Areas of Grievance work include:Appeals:
A member complaint involving an adverse benefit determination by an Alliance Utilization Management (UM) decision.Member Grievances
(Complaints) :
An oral or written statement submitted by a member or a member's authorized representative expressing dissatisfaction with any aspect of the Alliance's health care plan.Expedited Appeals/ Grievances:
A complaint or Appeal involving an imminent and serious threat to the health of the member, as determined by an Alliance Medical Director that includes, but is not limited to, severe pain, potential loss of life, limb or major bodily function.State Fair Hearings:
The process whereby a member enrolled in Medi-Cal requests the Department of Social Services (DSS) and its Administrative Law Division to resolve Plan decisions that deny, modify or delay health care services or affect Medi-Cal benefits.Inquiries:
A question or request for information or assistance by a member that does not reflect the member's dissatisfaction with any aspect of the Alliance's health care plan.Complex Member Billing Issues or Member Reimbursements:
When an Alliance member receives a bill from a medical provider for covered services or paid out of pocket for covered Medi-Cal services.
WHAT YOU'LL BE RESPONSIBLE FORSupporting the administration and resolution of medium complexity cases in support of the Alliance Grievance functionAssisting the Grievance and Quality Leadership with daily operations and serving as a backup for Grievance and Subject Matter Expert (SME) TrainingParticipating in departmental and cross departmental trainings, workgroups, and operational improvement activities
About the Team:We support the Alliance grievance function and follow all regulatory requirements. Our small yet mighty team works across the organization seeking to solve problems for our members while staying up to date on any policy changes. We manage case work with strict timeframes, communicate regularly with members, providers and within our team.THE IDEAL CANDIDATEHas a behavioral health background and awareness of possible patient issues while receiving behavioral health servicesIs capable of following business procedures while also comfortable working in grey or ambiguous situationsHas demonstrated experience and comfort with having difficult conversationsIs comfortable working in evolving environments and understands when discretion is neededHas the ability to communicate issues accurately and timelyIs detail oriented, highly organized and thrives in a fast-paced environmentHas a passion for presenting new ideas and collaborating with othersHas experience with managing cases and contributing to process improvementEasily wears multiple hats to get the work done, and enjoys being flexible along the way
WHAT YOU'LL NEED TO BE SUCCESSFULTo read the full position description, and list of requirements click here.Knowledge of:
Principles and practices of managed healthcare, healthcare coverage and benefit structures, principles of coordination of benefits and medical billingTitle 22 and Title 28 utilization management and grievance regulationsDiverse needs of the Medi-Cal populationPrinciples and practices of customer service
Ability to:
Understand and communicate the complex operations and processes of the Alliance, including those related to Utilization Management, Care Management and Member Services departmentsIdentify issues, conduct research and investigations, gather and analyze information, reach logical and sound conclusions, and offer recommendations and potential consequencesInterpret legal, regulatory and contractual language, policies, procedures and guidelines, and legislative and regulatory directivesPrepare reports, correspondence and other program documents
Education and Experience:
Bachelor's degree in Health, Social Science, or a related field and a minimum of three years of experience in a managed health care setting, health plan or provider office performing work related to processing provider claims, including a minimum of one year of experience administering provider disputes or member appeals and grievances (a Master's degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying
OTHER INFORMATIONWe are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft Teams.While some staff may work full-time telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected.In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process.
The full compensation range for this position is listed by location below.
The actual compensation for this role will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferrable experience related to the position, education or training), as well as other factors (internal equity, market factors, and geographic location).OTHER INFORMATIONWe are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft Teams.While some staff may work full telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected.In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process.
The full compensation range for this position is listed by location below.
The actual compensation for this role will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferrable experience related to the position, education or training), as well as other factors (internal equity, market factors, and geographic location).Santa Cruz County Pay Range $56,941-$91,125 USD Merced County Pay Range $51,816-$82,909 USD
OUR BENEFITSAvailable for all regular Alliance employees working more than 30 hours per week. Some benefits are available on a pro-rated basis for part-time employees. These benefits are unavailable to temporary employees while on an assignment with the Alliance.Medical, Dental and Vision PlansAmple Paid Time Off12 Paid Holidays per year401(a) Retirement Plan457 Deferred Compensation PlanRobust Health and Wellness ProgramOnsite EV Charging Stations
ABOUT USWe are a group of over 500 dedicated employees, committed to our mission of providing accessible, quality health care that is guided by local innovation. We feel that our work is bigger than ourselves. We leave work each day knowing that we made a difference in the community around us.Join us at Central California Alliance for Health (the Alliance), where you will be part of a culture that is respectful, diverse, professional and fun, and where you are empowered to do your best work. As a regional non-profit health plan, we serve members in Mariposa, Merced, Monterey, San Benito and Santa Cruz counties. To learn more about us, take a look at our
Fact Sheet .The Alliance is an equal employment opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), sexual orientation, gender perception or identity, national origin, age, marital status, protected veteran status, or disability status. We are an E-Verify participating employerAt this time the Alliance does not provide any type of sponsorship. Applicants must be currently authorized to work in the United States on a full-time, ongoing basis without current or future needs for any type of employer supported or provided sponsorship.
Merced County, California; Santa Cruz County, CaliforniaWe have an opportunity as a Grievance Specialist on the Grievance Team. *The focus for this role will be with behavioral health concerns.Grievance work involves complex coordination, investigation and specific resolution(s) within regulatory timeframes. Areas of Grievance work include:Appeals:
A member complaint involving an adverse benefit determination by an Alliance Utilization Management (UM) decision.Member Grievances
(Complaints) :
An oral or written statement submitted by a member or a member's authorized representative expressing dissatisfaction with any aspect of the Alliance's health care plan.Expedited Appeals/ Grievances:
A complaint or Appeal involving an imminent and serious threat to the health of the member, as determined by an Alliance Medical Director that includes, but is not limited to, severe pain, potential loss of life, limb or major bodily function.State Fair Hearings:
The process whereby a member enrolled in Medi-Cal requests the Department of Social Services (DSS) and its Administrative Law Division to resolve Plan decisions that deny, modify or delay health care services or affect Medi-Cal benefits.Inquiries:
A question or request for information or assistance by a member that does not reflect the member's dissatisfaction with any aspect of the Alliance's health care plan.Complex Member Billing Issues or Member Reimbursements:
When an Alliance member receives a bill from a medical provider for covered services or paid out of pocket for covered Medi-Cal services.
WHAT YOU'LL BE RESPONSIBLE FORSupporting the administration and resolution of medium complexity cases in support of the Alliance Grievance functionAssisting the Grievance and Quality Leadership with daily operations and serving as a backup for Grievance and Subject Matter Expert (SME) TrainingParticipating in departmental and cross departmental trainings, workgroups, and operational improvement activities
About the Team:We support the Alliance grievance function and follow all regulatory requirements. Our small yet mighty team works across the organization seeking to solve problems for our members while staying up to date on any policy changes. We manage case work with strict timeframes, communicate regularly with members, providers and within our team.THE IDEAL CANDIDATEHas a behavioral health background and awareness of possible patient issues while receiving behavioral health servicesIs capable of following business procedures while also comfortable working in grey or ambiguous situationsHas demonstrated experience and comfort with having difficult conversationsIs comfortable working in evolving environments and understands when discretion is neededHas the ability to communicate issues accurately and timelyIs detail oriented, highly organized and thrives in a fast-paced environmentHas a passion for presenting new ideas and collaborating with othersHas experience with managing cases and contributing to process improvementEasily wears multiple hats to get the work done, and enjoys being flexible along the way
WHAT YOU'LL NEED TO BE SUCCESSFULTo read the full position description, and list of requirements click here.Knowledge of:
Principles and practices of managed healthcare, healthcare coverage and benefit structures, principles of coordination of benefits and medical billingTitle 22 and Title 28 utilization management and grievance regulationsDiverse needs of the Medi-Cal populationPrinciples and practices of customer service
Ability to:
Understand and communicate the complex operations and processes of the Alliance, including those related to Utilization Management, Care Management and Member Services departmentsIdentify issues, conduct research and investigations, gather and analyze information, reach logical and sound conclusions, and offer recommendations and potential consequencesInterpret legal, regulatory and contractual language, policies, procedures and guidelines, and legislative and regulatory directivesPrepare reports, correspondence and other program documents
Education and Experience:
Bachelor's degree in Health, Social Science, or a related field and a minimum of three years of experience in a managed health care setting, health plan or provider office performing work related to processing provider claims, including a minimum of one year of experience administering provider disputes or member appeals and grievances (a Master's degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying
OTHER INFORMATIONWe are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft Teams.While some staff may work full-time telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected.In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process.
The full compensation range for this position is listed by location below.
The actual compensation for this role will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferrable experience related to the position, education or training), as well as other factors (internal equity, market factors, and geographic location).OTHER INFORMATIONWe are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft Teams.While some staff may work full telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected.In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process.
The full compensation range for this position is listed by location below.
The actual compensation for this role will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferrable experience related to the position, education or training), as well as other factors (internal equity, market factors, and geographic location).Santa Cruz County Pay Range $56,941-$91,125 USD Merced County Pay Range $51,816-$82,909 USD
OUR BENEFITSAvailable for all regular Alliance employees working more than 30 hours per week. Some benefits are available on a pro-rated basis for part-time employees. These benefits are unavailable to temporary employees while on an assignment with the Alliance.Medical, Dental and Vision PlansAmple Paid Time Off12 Paid Holidays per year401(a) Retirement Plan457 Deferred Compensation PlanRobust Health and Wellness ProgramOnsite EV Charging Stations
ABOUT USWe are a group of over 500 dedicated employees, committed to our mission of providing accessible, quality health care that is guided by local innovation. We feel that our work is bigger than ourselves. We leave work each day knowing that we made a difference in the community around us.Join us at Central California Alliance for Health (the Alliance), where you will be part of a culture that is respectful, diverse, professional and fun, and where you are empowered to do your best work. As a regional non-profit health plan, we serve members in Mariposa, Merced, Monterey, San Benito and Santa Cruz counties. To learn more about us, take a look at our
Fact Sheet .The Alliance is an equal employment opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), sexual orientation, gender perception or identity, national origin, age, marital status, protected veteran status, or disability status. We are an E-Verify participating employerAt this time the Alliance does not provide any type of sponsorship. Applicants must be currently authorized to work in the United States on a full-time, ongoing basis without current or future needs for any type of employer supported or provided sponsorship.