Remote CA Appeals & Grievances Case Manager

Pyramid Consulting Healthcare; California; Remote; USD 37,000 - 43,000; Full time

Benefits offered by this job

Traveler benefits

Remote in CA

Job summary

Pyramid Consulting, Inc. is seeking an Appeals & Grievances Case Manager for a CA-based remote contract assignment. The role demands handling member complaints, grievances, and appeals with strict regulatory adherence.

Requirements include 5+ years in Appeals & Grievances within a health plan or managed care, plus 2+ years in related areas and knowledge of CMS/DMHC/NCQA standards. Remote CA opportunity with travel-friendly agency benefits.

Qualifications

• 5+ years of Appeals & Grievances experience within a Health Plan or Managed Care organization.
• 2+ years experience in Appeals, Grievances, Utilization Management, or Care Coordination in a health plan or TPA.
• Strong understanding of CMS, DMHC, and NCQA regulatory standards.
• Experience reviewing medical records and clinical documentation.

Responsibilities

• Investigate, coordinate, and resolve member complaints, grievances, and appeals in compliance with health plan standards.
• Ensure timely and fair resolutions with accurate documentation and cross-functional collaboration.

Skills

Appeals & Grievances experience

Regulatory compliance

Medical records review

Cross-functional collaboration

Job description

Pyramid Consulting, Inc. is seeking an Appeals & Grievances Case Manager for a CA-based remote contract assignment. The role demands handling member complaints, grievances, and appeals with strict regulatory adherence.

Requirements include 5+ years in Appeals & Grievances within a health plan or managed care, plus 2+ years in related areas and knowledge of CMS/DMHC/NCQA standards. Remote CA opportunity with travel-friendly agency benefits.