Customer Solution Center Appeals and Grievances Specialist II
Job Category: Customer Service
Location: Los Angeles, CA, US, 90017
Position Type: Full Time
Requisition ID: 11505
Salary 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.
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.
Job Summary
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 regulatory requirements from CMS, DHCS, DMHC, MRMIB, and NCQA. Responsibilities include reviewing pre-service authorizations, concurrent and post-service medical necessity, benefit coverage appeals, and complex provider claim disputes.
The position is responsible for maintaining the privacy and confidentiality of information, protecting the organization's assets, acting with ethics and integrity, and adhering to company policies 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 A&G database by thorough, timely, and accurate assignment of cases.
- Prepares and analyzes monthly appeal and grievance reports.
- Participates in internal and external oversight activities and recommends opportunities for improvement.
- Performs other duties as assigned.
Education Required
Associate's Degree or 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.
- Experience working with firm deadlines and interpreting regulations.
- 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, and able to exercise strong independent judgment.
- Conflict resolution and persuasion skills.
- Excellent communication and presentation skills.
- Proficient in MS Office applications.
- Strong knowledge of regulatory standards and claims processing.
Preferred: Proficient in MS Access and Visio.
Licenses/Certifications Required
Licenses/Certifications Preferred
Required Training
Physical Requirements
Light
Additional 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.
L.A. Care offers a wide range of benefits including:
- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental, and Vision
- Wellness Program
Nearest Major Market: Los Angeles
Job Segment: Claims, Medicare, Medicaid, Healthcare, Insurance
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