Grievance Resolution Specialist

CalOptima; Orange (CA); Ibrido; USD 54.000 - 81.000; Tempo pieno

Vantaggi offerti da questo lavoro

A generous PTO program

Quality work life balance

Wellness programs

Tuition Reimbursement

Professional development opportunities

Career development opportunities

Flexible scheduling

Descrizione del lavoro

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.

Competenze

• 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.

Mansioni

• 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.

Conoscenze

Grievance & Appeals knowledge

Customer service

Communication

Regulatory compliance

Formazione

High school diploma or equivalent

Associate degree in business (preferred)

Descrizione del lavoro

Grievance Resolution Specialist

CalOptima

Join Us in this Amazing Opportunity

The Team You'll Join

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.

More About the Opportunity

We are hoping you will join us as a Grievance Resolution Specialist and help shape the future of healthcare where you'll be an integral part of our Grievance & Appeals team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Partial Telework.

- If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.

The Grievance Resolution Specialist will be responsible for coordinating the grievance and appeal resolution process. The incumbent will respond to verbal and written grievances and appeals from members and providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions and pharmacy and vision decisions. You will have frequent external contact with members and families, health care providers, health networks, third party administrators and regulators. You will collaborate with internal departments such as Customer Service, Provider Relations, Pharmacy and Medical Management to identify factors necessary for the optimal resolution of Grievances and Appeals. Together, we are building a stronger, more equitable health system.

Your Contributions To the Team:

• 80% - Program Support
• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Maintains adequate information in CalOptima Health's systems; ensures data collection, summarization, integration and reporting, including case creation and management and events/activity tracking.
• Gathers pertinent information regarding the grievances and appeals received, including member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal, or supplemental information required to evaluate grievances and appeals within regulatory requirements.
• Coordinates and participates in case discussions with operational experts to result in a final case disposition as needed.
• Evaluates case details, proposes recommendations, or makes decisions as applicable, ensures the organization's decision is implemented according to the Grievance and Appeals policies and case resolution.
• Develops resolution letters and correspondence to members and providers.
• Communicates with internal and external customers to ensure timely review and resolution of grievances or appeals.
• Initiates referrals to the Quality Improvement department as applicable and facilitates responses to members according to CalOptima Health policy.
• 15% - Administrative Support
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Assists with health networks' compliance process.
• Meets performance measurement goals for Grievance and Appeals Resolution Services (GARS).
• Identifies trends and root cause of issues, proposes solutions, or escalates ongoing issues to management.
• 5% - Other
• Completes other projects and duties as assigned.

Do You Have What the Role Requires?

• High school diploma or equivalent PLUS 1 year of experience in grievances and appeals, claims, regulatory compliance, customer service or related field required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

You'll Stand Out More If You Possess the Following:

• Associate degree in business, health care administration or related field.
• Experience in health care practice standards for both government and commercial plans.
• Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Russian, Spanish, Vietnamese).

What the Regulatory Agencies Need You to Possess?

N/A

Your Knowledge & Abilities to Bring to this Role:

• Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events.
• Organize, be analytical, problem-solve and possess project management skills.
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees/coalitions.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Your Physical Requirements (With or Without Accommodations):

• Ability to visually read information from computer screens, forms and other printed materials and information.
• Ability to speak (enunciate) clearly in conversation and general communication.
• Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
• Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
• Lifting and moving objects, patients and/or equipment 10 to 25 pounds

Ways We Are Here For You

• You'll enjoy competitive compensation for this role.
• Our current hiring range is: Pay Grade: 304 - $53,813 - $80,720 ($25.87 - $38.8077).
• The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors.
• This position is approved for Partial Telework (**If the position is Telework, it is eligible in California only**)
• CalPERS pension program and additional retirement packages.
• Additional benefits and perks including:

• A generous PTO program
• A quality work life balance
• Various wellness programs
• Tuition Reimbursement
• Professional development opportunities
• Career development opportunities
• Flexible scheduling
• And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.

Our Work Environment:

If located at the 500, 505 Building or a remote work location:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• There are no harmful environmental conditions present for this job.
• The noise level in this work environment is usually moderate.

If located at PACE:

• Work is typically indoors in a clinical setting serving the frail and elderly.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

If located in the Community:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• Employee will occasionally work outdoors in varied temperatures.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

Why Join Us?

We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impacts on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare.

What’s Your Next Step?

Deadline for the first review of applications is October 26, 2026 at 9:00 PM (PST).

If you apply after the first review date, your application is not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date.

Our Commitment to You

If you make it through the steps above and are selected for this exciting role, you will be required to undergo a reference and a background check (to include a conviction record) and if applicable also pass a drug screening and/or a post-offer pre-employment medical examination (for specific positions).

CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at [phone] if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.