Hybrid Grievance & Appeals Specialist

CalOptima Health Partnership; Orange (CA); Hybrid; USD 54.000 - 81.000; Vollzeit

Benefits dieser Stelle

Partial Telework

Comprehensive benefits package

CalPERS pension program

Generous PTO program

Tuition Reimbursement

Professional development opportunities

Flexible scheduling

Zusammenfassung

CalOptima Health seeks a Grievance Resolution Specialist to coordinate the grievance and appeal process, handling verbal and written inquiries from members and providers. The role involves collaboration with providers, networks, and regulators to resolve cases and ensure compliance under CalOptima Health policies.

The position supports a partial telework arrangement with in-office presence in Orange, CA at least two days per week, and interacts with multiple internal teams to improve member

Qualifikationen

• High school diploma or equivalent PLUS 1 year of experience in grievances and appeals, claims, regulatory compliance, customer service or related field.

Aufgaben

• Coordinate and respond to grievances and appeals from members and providers.
• Collaborate with internal departments to resolve cases per policy.
• Prepare resolution letters and communications to members/providers.
• Maintain case information and tracking in relevant systems.
• Identify trends and flags for quality improvement and regulatory compliance.

Kenntnisse

Grievances & Appeals

Customer Service

Regulatory Compliance

Data Entry

Microsoft Office

Ausbildung

High school diploma or equivalent

Tools

Microsoft Office

Jobbeschreibung

CalOptima Health seeks a Grievance Resolution Specialist to coordinate the grievance and appeal process, handling verbal and written inquiries from members and providers. The role involves collaboration with providers, networks, and regulators to resolve cases and ensure compliance under CalOptima Health policies.

The position supports a partial telework arrangement with in-office presence in Orange, CA at least two days per week, and interacts with multiple internal teams to improve member