Hybrid Appeals & Grievances Specialist II

L.A. Care Health Plan; Los Angeles (CA); Híbrido; USD 61 000 - 91 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Paid Time Off (PTO)

Tuition Reimbursement

Retirement Plans

Medical, Dental and Vision

Wellness Program

Volunteer Time Off (VTO)

Resumo da oferta

L.A. Care Health Plan in Los Angeles, CA seeks an Appeals and Grievances Specialist II to investigate and resolve member and provider complaints and appeals with strong independent judgment. You will review medical necessity, benefit coverage appeals, and provider disputes while ensuring regulatory compliance.

The role requires experience in Managed Care, familiarity with CMS/DHCS/DMHC/NCQA standards, meticulous case management, and collaboration with internal teams to drive timely resolutions.

Qualificações

• At least 2 years of experience in Managed Care with specific experience in resolving member and provider complaint and appeals issues, including eligibility, access to care, claims, benefit, and quality of care concerns.
• Experience working with firm deadlines, able to interpret and apply regulations.
• At least 5 years of experience in Managed Care working with Medicare, Medi-Cal and other State Sponsored programs.
• Knowledge of Medical terminology and strong advocacy experience.

Responsabilidades

• Identifies, investigates, and resolves administrative complaints, complex provider appeals and State Fair Hearing adhering to CMS, DHCS, DMHC, MRMIB and NCQA standards and regulations.
• Intakes, acknowledges, prepares case files and routes complaints to appropriate internal department for investigation.
• Ensures integrity of A&G database by thorough, timely and accurate assignment of cases.
• Monitors closure of complaints and works with Quality Control Supervisor to resolve all database issues.
• Prepare and analyze monthly appeal and grievance reports.
• Participates in internal and external oversight activities, inter-rater reliability reviews and focused audits.
• Perform other duties as assigned.

Conhecimentos

Regulatory knowledge

Claims processing

Communication

Presentation skills

MS Office

Team player

Detail oriented

Independent judgment

Conflict resolution

Persuasion

Formação académica

Associate's Degree

Bachelor's Degree

Ferramentas

Access

Visio

Descrição da oferta de emprego

L.A. Care Health Plan in Los Angeles, CA seeks an Appeals and Grievances Specialist II to investigate and resolve member and provider complaints and appeals with strong independent judgment. You will review medical necessity, benefit coverage appeals, and provider disputes while ensuring regulatory compliance.

The role requires experience in Managed Care, familiarity with CMS/DHCS/DMHC/NCQA standards, meticulous case management, and collaboration with internal teams to drive timely resolutions.