Grievance & Appeals Specialist (Partial Telework)

CalOptima; Orange (CA); Hybrid; USD 54,000 - 81,000; Full time

Benefits offered by this job

A generous PTO program

Quality work life balance

Wellness programs

Tuition Reimbursement

Professional development opportunities

Career development opportunities

Flexible scheduling

Job summary

CalOptima Health is seeking a Grievance Resolution Specialist in California to manage the grievance and appeal process, coordinating with providers, members, and internal teams. The role emphasizes timely, compliant resolution and clear member communication.

Partial Telework is approved with requirements to work within California and visit the Orange main office at least two days per week. Strong data handling and cross-functional collaboration are essential for success.

Qualifications

• Must have high school diploma or equivalent plus 1 year of experience in grievances and appeals, claims, regulatory compliance, customer service or related field.
• Bilingual in English and one threshold language (Arabic, Farsi, Chinese, Korean, Russian, Spanish, Vietnamese) is a plus.
• Experience in health care practice standards for government and commercial plans is preferred.

Responsibilities

• Coordinate grievance and appeal resolution process.
• Respond to verbal and written grievances and appeals from members and providers.
• Collaborate with internal departments to identify factors for optimal resolution.

Skills

Grievance & Appeals knowledge

Customer service

Communication

Regulatory compliance

Education

High school diploma or equivalent

Associate degree in business (preferred)

Job description

CalOptima Health is seeking a Grievance Resolution Specialist in California to manage the grievance and appeal process, coordinating with providers, members, and internal teams. The role emphasizes timely, compliant resolution and clear member communication.

Partial Telework is approved with requirements to work within California and visit the Orange main office at least two days per week. Strong data handling and cross-functional collaboration are essential for success.