Grievance & Appeals Specialist (Temp)

Santa Clara County Health Plan; San Jose (CA); On-site; USD 67,863 - 101,795; Full time

Job summary

Santa Clara County Health Plan is seeking a Temp Grievance and Appeals Coordinator to manage the end-to-end grievance and appeals process for members and providers across all lines of business, in compliance with state and federal regulations.

Responsibilities include intake, research, documentation, case escalation, and preparation for hearings, with emphasis on accuracy, timeliness, and collaboration with internal teams and external stakeholders.

Qualifications

• High School diploma or GED.
• Minimum two years of experience in customer service, provider service, health service, or pharmacy in a managed care or health care environment handling escalated or complex issues.
• Knowledge of health plan benefits, processes and operations.
• Prior experience with commercial, Medi-Cal and/or Medicare programs and working with the underserved populations.
• Work weekends and company holidays as needed based on business regulatory requirements.

Responsibilities

• Act as a back-up to the Grievance and Appeals Intake Specialist during times of high volume work and/or staffing shortages to ensure appropriate intake of new and existing grievance and appeal cases, assessing the priority of each case and routing to the appropriate staff.
• Ensure grievance and appeals cases are accurate and include the necessary elements for processing and resolving, giving special attention to those identified as Expedite. Create clear and concise documentation in applicable system(s).
• Use good judgment and department resources to identify all issues and required actions within a case, appropriately categorize cases and identify required actions in accordance with state and federal regulations.
• Produce and manage outbound documents, correspondence and reports in a manner that meets required timeframes.
• Ensure adherence with state and federal regulatory timeframes for handling cases including acknowledging cases, resolving cases, monitoring effectuation of resolution, completing resolution letters and communicating with members and providers within required timeframes.

Skills

Customer service

Communication

Attention to detail

De-escalation

Multitasking

Education

Associate's degree or equivalent

Tools

Outlook

Word

Excel

Job description

Santa Clara County Health Plan is seeking a Temp Grievance and Appeals Coordinator to manage the end-to-end grievance and appeals process for members and providers across all lines of business, in compliance with state and federal regulations.

Responsibilities include intake, research, documentation, case escalation, and preparation for hearings, with emphasis on accuracy, timeliness, and collaboration with internal teams and external stakeholders.