Grievance & Appeals Support Specialist

CalOptima Health Partnership; Orange (CA); On-site; USD 50,000 - 70,000; Full time

Job summary

CalOptima Health in California is seeking a detail‑oriented administrator to join the Grievance & Appeals team. You will support department priorities, provide member‑focused service, and serve as the primary contact for inquiries related to grievances and appeals.

Duties include monitoring complaints via the Customer Service system, coordinating with internal departments and regulatory bodies such as DMHC and CMS, and setting up case files in the GARS system with accurate classifications.

Qualifications

• High school diploma or equivalent plus 1 year of experience in appeal and grievance guidelines, Medi-Cal/Medicaid or Medicare programs.
• Equivalent combination of education and experience may qualify.

Responsibilities

• Serve as the point of contact for grievances and appeals inquiries.
• Monitor incoming complaints via the Customer Service system from members and providers.
• Set up complaint case files and enter cases in the GARS system with accurate classification.
• Generate acknowledgment letters for all lines of business per regulatory standards.
• Coordinate administrative support for state hearings and related documentation.

Education

High school diploma or equivalent

Tools

GARS system

Microsoft Office

Job description

CalOptima Health in California is seeking a detail‑oriented administrator to join the Grievance & Appeals team. You will support department priorities, provide member‑focused service, and serve as the primary contact for inquiries related to grievances and appeals.

Duties include monitoring complaints via the Customer Service system, coordinating with internal departments and regulatory bodies such as DMHC and CMS, and setting up case files in the GARS system with accurate classifications.