Appeals and Grievances Specialist II

L.A. Care Health Plan; Los Angeles (CA); Hybrid; USD 61,000 - 91,000; Full time

Benefits offered by this job

Paid Time Off (PTO)

Tuition Reimbursement

Retirement Plans

Medical, Dental and Vision

Wellness Program

Volunteer Time Off (VTO)

Job summary

L.A. Care Health Plan in Los Angeles, CA seeks an Appeals and Grievances Specialist II to investigate and resolve member and provider complaints and appeals with strong independent judgment. You will review medical necessity, benefit coverage appeals, and provider disputes while ensuring regulatory compliance.

The role requires experience in Managed Care, familiarity with CMS/DHCS/DMHC/NCQA standards, meticulous case management, and collaboration with internal teams to drive timely resolutions.

Qualifications

• At least 2 years of experience in Managed Care with specific experience in resolving member and provider complaint and appeals issues, including eligibility, access to care, claims, benefit, and quality of care concerns.
• Experience working with firm deadlines, able to interpret and apply 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.

Responsibilities

• 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 department for investigation.
• Ensures integrity of A&G database by thorough, timely and accurate assignment of cases.
• Monitors closure of complaints and works with Quality Control Supervisor to resolve all database issues.
• Prepare and analyze monthly appeal and grievance reports.
• Participates in internal and external oversight activities, inter-rater reliability reviews and focused audits.
• Perform other duties as assigned.

Skills

Regulatory knowledge

Claims processing

Communication

Presentation skills

MS Office

Team player

Detail oriented

Independent judgment

Conflict resolution

Persuasion

Education

Associate's Degree

Bachelor's Degree

Tools

Access

Visio

Job description

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, we make sure our members get the right care at the right place at the right time.

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 and to support the safety net required to achieve that purpose.

Job Summary

The 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 Centers for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MBMIB) and National Committee for Quality Assurance (NCQA) regulatory requirements. This position reviews pre-service authorizations, concurrent and post-service (retroactive review) medical necessity, benefit coverage appeals and reconsiderations, and complex provider claim disputes. The position is further responsible for tracking, trending and reporting complaints and appeals, as well as participating in internal and external oversight activities.

The position is responsible for maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting noncompliance, adhering to company policy and procedures, including accreditation requirements, applicable federal, state and local 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 department for investigation and resolution, exercising strong independent judgment.

Ensures integrity of A&G database by thorough, timely and accurate assignment of cases. Monitors closure of complaints and works with Quality Control Supervisor to resolve all database issues.

Prepare and analyze 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

Perform 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, including eligibility, access to care, claims, benefit, and quality of care concerns.

Experience working with firm deadlines, able to interpret and apply 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:

Must be organized, detail oriented, able to exercise strong independent judgment; poses conflict resolution and persuasion skills.

A team player with excellent communication and presentation skills, able to work effectively with various internal departments/service areas, plan partners, participating provider groups and other external agencies.

Proficient in MS Office applications, Word, Excel and Power Point.

Requires strong knowledge of regulatory standards and claims processing; strong analytical, oral, written and presentation skills, able to monitor and be compliant with strict regulatory deadlines.

Preferred

Proficient in Access and Visio.

Physical Requirements

Light

Additional Information

This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call.

This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned

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
• Volunteer Time Off (VTO)