Appeals & Grievances Case Manager (California)

Pyramid Consulting, Inc; Los Angeles (CA); Remoto; USD 37.000 - 43.000; Tempo pieno

Vantaggi offerti da questo lavoro

Traveler benefits

Descrizione del lavoro

Pyramid Consulting, Inc. is seeking an Appeals & Grievances Case Manager for a California-based contract role in Los Angeles, with remote work options.

The position targets candidates with extensive appeals experience in health plans, including member and provider appeals, authorization appeals, and benefit determinations. Ideal applicants will have a solid grasp of CMS, DMHC, and NCQA standards, plus proven ability to review medical records and clinical documentation.

Competenze

• 5+ years of Appeals & Grievances experience within a Health Plan or Managed Care organization.
• Experience handling: Member Appeals, Provider Appeals, Authorization Appeals, Benefit Determinations.
• Strong understanding of CMS, DMHC, and NCQA regulatory standards.
• Experience reviewing medical records and clinical documentation.

Conoscenze

Appeals experience

CMS knowledge

Regulatory standards

Medical records review

Health plan experience

Descrizione del lavoro

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 Los Angeles, CA (Remote).

Job ID:26-31017

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

Key Requirements and Technology Experience:

• 5+ years of Appeals & Grievances experience within a Health Plan or Managed Care organization
• Experience handling:
• Member Appeals
• Provider Appeals
• Authorization Appeals
• Benefit Determinations
• CMS
• DMHC
• NCQA
• Medi-Cal
• Commercial Health Plans
• Experience reviewing medical records and clinical documentation
• 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.

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.