Department(s): Grievance & Appeals Resolution Services (GARS)
Reports to: Manager, Grievance & Appeals
FLSA status: Non-Exempt
Salary Grade: F - $51,000 - $78,122
Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on Tuesday, February 13, 2024 at 11:59 PM. Applicants are encouraged to apply early. This recruitment may close at any time without notice after the first review date.
About CalOptima Health
CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto — "Better. Together.” — is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community’s health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring.
About the Position
The Grievance Resolution Specialist will be responsible for coordinating the grievance and appeal resolution process. The incumbent will respond to verbal and written grievances and appeals from members and providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions and pharmacy and vision decisions. The incumbent will have frequent external contact with members and families, health care providers, health networks, third party administrators and regulators. The incumbent will collaborate with internal departments such as Customer Service, Provider Relations, Pharmacy and Medical Management to identify factors necessary for the optimal resolution of Grievances and Appeals.
Duties & Responsibilities:
- Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
- Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
- Maintains adequate information in CalOptima Health’s systems; ensures data collection, summarization, integration and reporting which includes case creation and management and events/activity tracking.
- Gathers pertinent information regarding the grievances and appeals received including member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal, or supplemental information required to evaluate grievances and appeals within regulatory requirements.
- Coordinates and/or participates in case discussion with operational experts to result in a final case disposition as needed.
- Evaluates case details, proposes recommendations or makes decisions 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 grievances or appeals.
- Initiates referrals to Quality Improvement department as applicable and facilitates responses to members according to CalOptima Health policy.
- Assists with health networks’ compliance process.
- Identifies trends and root cause of issues, proposes solutions or escalates ongoing issues to management.
- Meets performance measurement goals for Grievance and Appeals Resolution Services.
- Completes other projects and duties as assigned.
Experience & Education:
- High School diploma or equivalent required.
- 1 year of experience in any of the following areas: Grievances and Appeals, Claims, Regulatory Compliance, Customer Service or related fields required.
- An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
Preferred Qualifications:
- Associate’s 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 in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).
Physical Demands and Work Environment:
The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Physical demands: While performing duties of job, employee may be required to move about the organization and to travel to offsite locations. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Must also be able to reach with hands and arms and must occasionally lift office supply boxes or laptop case while traveling, up to 25 pounds. Employee must be able to communicate, particularly for regular phone use, in meetings, face-to-face interaction and while presenting.
Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures. Work is performed at workstation; there are steps and elevators available to access the work areas. All floors have keypad controls for the safety of the employee.
About our Benefits & Wellness options:
At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.
CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.
CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws.
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