L.A. Care Health Plan
Customer Solution Center Appeals and Grievances Specialist II (ALD)
L.A. Care Health Plan, Los Angeles, California, United States, 90079
Customer Solution Center Appeals and Grievances Specialist II (ALD)
Job Category:
Customer ServiceLocation:
Los Angeles, CA, US, 90017Position Type:
Full TimeRequisition ID:
11362Salary Range:
$60,778.00 (Min.) - $75,950.00 (Mid.) - $91,166.00 (Max.)Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan, serving more than 2 million members in five health plans.Mission:
L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents.The Customer Solution Center 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 CMS, DHCS, DMHC, MRMIB, and NCQA regulatory requirements. Responsibilities include reviewing pre-service authorizations, concurrent and post-service medical necessity, benefit coverage appeals, and complex provider claim disputes. The position is also responsible for tracking, trending, and reporting complaints and appeals, as well as participating in internal and external oversight activities.The position requires maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting noncompliance, and adhering to company policies and procedures, including accreditation requirements and applicable 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 departments for investigation and resolution.Ensures integrity of the A&G database by thorough, timely, and accurate assignment of cases.Monitors closure of complaints and works with Quality Control Supervisor to resolve database issues.Prepares and analyzes 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.Performs other duties as assigned.Education Required
Associate's Degree. In lieu of degree, equivalent education and/or experience may be considered.Education Preferred
Bachelor's Degree.Experience
Required:At least 2 years of experience in Managed Care with specific experience in resolving member and provider complaint and appeals issues.At least 5 years of experience in Managed Care working with Medicare, Medi-Cal, and other State Sponsored programs.Knowledge of Medical terminology and strong advocacy experience.Skills
Required:Organized, detail-oriented, able to exercise strong independent judgment; possesses conflict resolution and persuasion skills.Excellent communication and presentation skills, able to work effectively with various internal departments/service areas.Proficient in MS Office applications, Word, Excel, and PowerPoint.Strong knowledge of regulatory standards and claims processing; strong analytical, oral, written, and presentation skills.Preferred:
Proficient in MS Office applications, Access, Visio.Licenses/Certifications Required
Licenses/Certifications Preferred
Required Training
Physical Requirements
LightAdditional Information
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.This position is a limited duration position. The term is a minimum of one year and a maximum of two years from the start date unless terminated earlier by either party. Limited duration positions are full-time and eligible for full benefits.L.A. Care offers a wide range of benefits including:Paid Time Off (PTO)Tuition ReimbursementRetirement PlansMedical, Dental, and VisionWellness ProgramNearest Major Market:
Los AngelesJob Segment:
Claims, Medicare, Medicaid, Insurance, Healthcare
#J-18808-Ljbffr
Job Category:
Customer ServiceLocation:
Los Angeles, CA, US, 90017Position Type:
Full TimeRequisition ID:
11362Salary Range:
$60,778.00 (Min.) - $75,950.00 (Mid.) - $91,166.00 (Max.)Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan, serving more than 2 million members in five health plans.Mission:
L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents.The Customer Solution Center 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 CMS, DHCS, DMHC, MRMIB, and NCQA regulatory requirements. Responsibilities include reviewing pre-service authorizations, concurrent and post-service medical necessity, benefit coverage appeals, and complex provider claim disputes. The position is also responsible for tracking, trending, and reporting complaints and appeals, as well as participating in internal and external oversight activities.The position requires maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting noncompliance, and adhering to company policies and procedures, including accreditation requirements and applicable 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 departments for investigation and resolution.Ensures integrity of the A&G database by thorough, timely, and accurate assignment of cases.Monitors closure of complaints and works with Quality Control Supervisor to resolve database issues.Prepares and analyzes 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.Performs other duties as assigned.Education Required
Associate's Degree. In lieu of degree, equivalent education and/or experience may be considered.Education Preferred
Bachelor's Degree.Experience
Required:At least 2 years of experience in Managed Care with specific experience in resolving member and provider complaint and appeals issues.At least 5 years of experience in Managed Care working with Medicare, Medi-Cal, and other State Sponsored programs.Knowledge of Medical terminology and strong advocacy experience.Skills
Required:Organized, detail-oriented, able to exercise strong independent judgment; possesses conflict resolution and persuasion skills.Excellent communication and presentation skills, able to work effectively with various internal departments/service areas.Proficient in MS Office applications, Word, Excel, and PowerPoint.Strong knowledge of regulatory standards and claims processing; strong analytical, oral, written, and presentation skills.Preferred:
Proficient in MS Office applications, Access, Visio.Licenses/Certifications Required
Licenses/Certifications Preferred
Required Training
Physical Requirements
LightAdditional Information
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.This position is a limited duration position. The term is a minimum of one year and a maximum of two years from the start date unless terminated earlier by either party. Limited duration positions are full-time and eligible for full benefits.L.A. Care offers a wide range of benefits including:Paid Time Off (PTO)Tuition ReimbursementRetirement PlansMedical, Dental, and VisionWellness ProgramNearest Major Market:
Los AngelesJob Segment:
Claims, Medicare, Medicaid, Insurance, Healthcare
#J-18808-Ljbffr