Appeals & Grievances Case Manager (California)

Pyramid Consulting Healthcare; California; Remote; USD 37,000 - 43,000; Full time

Benefits offered by this job

Traveler benefits

Remote in CA

Job summary

Pyramid Consulting, Inc. is seeking an Appeals & Grievances Case Manager for a CA-based remote contract assignment. The role demands handling member complaints, grievances, and appeals with strict regulatory adherence.

Requirements include 5+ years in Appeals & Grievances within a health plan or managed care, plus 2+ years in related areas and knowledge of CMS/DMHC/NCQA standards. Remote CA opportunity with travel-friendly agency benefits.

Qualifications

• 5+ years of Appeals & Grievances experience within a Health Plan or Managed Care organization.
• 2+ years experience in Appeals, Grievances, Utilization Management, or Care Coordination in a health plan or TPA.
• Strong understanding of CMS, DMHC, and NCQA regulatory standards.
• Experience reviewing medical records and clinical documentation.

Responsibilities

• Investigate, coordinate, and resolve member complaints, grievances, and appeals in compliance with health plan standards.
• Ensure timely and fair resolutions with accurate documentation and cross-functional collaboration.

Skills

Appeals & Grievances experience

Regulatory compliance

Medical records review

Cross-functional collaboration

Job description

Immediate need for a talented Appeals & Grievances Case Manager (California) . This is a 06+ Months Contract opportunity with long-term potential and is located in California (Remote).

Job ID:26-31017

Pay Range: $27 - $31/hour. Traveler benefits as per agency package. (Benefits vary by vendor and assignment.)

Key Responsibilities:

• We are seeking a detail-oriented Case Manager - Appeals & Grievances to investigate, coordinate, and resolve member complaints, grievances, and appeals in compliance with health plan and regulatory standards.
• This role ensures timely and fair resolutions, accurate documentation, and strong cross-functional collaboration.

Key Requirements and Technology Experience:

• 2+ years experience in Appeals, Grievances, Utilization Management, or Care Coordination in a health plan or TPA.
• Strong understanding of CMS, DMHC, and NCQA regulatory standards.
• Required Qualifications
• 5+ years of Appeals & Grievances experience within a Health Plan or Managed Care organization
• Experience handling:
• Member Appeals
• Provider Appeals
• Authorization Appeals
• Benefit Determinations
• Knowledge of:
• CMS
• DMHC
• NCQA
• Medi-Cal
• Commercial Health Plans
• Experience reviewing medical records and clinical documentation

Our client is a leading Healthcare Industry and we are currently interviewing to fill this and other similar contract positions.

Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.