Senior Appeals & Grievances Specialist - Hybrid/Remote

L.A. Care Health Plan; Los Angeles (CA); Hybrid; USD 61,000 - 91,000; Full time

Benefits offered by this job

Paid Time Off

Tuition Reimbursement

Retirement Plans

Medical, Dental and Vision

Wellness Program

Volunteer Time Off (VTO)

Job summary

L.A. Care Health Plan in Los Angeles is seeking an experienced Appeals and Grievances (A&G) Specialist II to investigate and resolve member and provider complaints and appeals with strong independent judgment.

You will ensure compliance with CMS, DHCS, DMHC, MBMIB and NCQA standards, review medical necessity, benefit coverage and complex provider disputes, and support reporting and oversight activities.

Qualifications

• Experience in managed care with member/provider complaints and appeals.
• Ability to meet firm deadlines and apply regulations.
• Strong advocacy, medical terminology knowledge.

Responsibilities

• 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 and resolution, exercising strong independent judgment.
• 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 to meet internal and external reporting requirements.
• Participates in internal and external oversight activities, inter-rater reliability reviews and focused audits. Recommends opportunities for improvement
• Perform other duties as assigned.

Skills

Organization & attention to detail

Communication & presentation

MS Office proficiency

Regulatory knowledge

Education

Associate's Degree

Bachelor's Degree

Tools

Access

Visio

Job description

L.A. Care Health Plan in Los Angeles is seeking an experienced Appeals and Grievances (A&G) Specialist II to investigate and resolve member and provider complaints and appeals with strong independent judgment.

You will ensure compliance with CMS, DHCS, DMHC, MBMIB and NCQA standards, review medical necessity, benefit coverage and complex provider disputes, and support reporting and oversight activities.