Y - As Needed / Temp - Program Assistant (GARS)

CalOptima Health Partnership; Orange (CA); On-site; USD 50,000 - 70,000; Full time

Job summary

CalOptima Health in California is seeking a detail‑oriented administrator to join the Grievance & Appeals team. You will support department priorities, provide member‑focused service, and serve as the primary contact for inquiries related to grievances and appeals.

Duties include monitoring complaints via the Customer Service system, coordinating with internal departments and regulatory bodies such as DMHC and CMS, and setting up case files in the GARS system with accurate classifications.

Qualifications

• High school diploma or equivalent plus 1 year of experience in appeal and grievance guidelines, Medi-Cal/Medicaid or Medicare programs.
• Equivalent combination of education and experience may qualify.

Responsibilities

• Serve as the point of contact for grievances and appeals inquiries.
• Monitor incoming complaints via the Customer Service system from members and providers.
• Set up complaint case files and enter cases in the GARS system with accurate classification.
• Generate acknowledgment letters for all lines of business per regulatory standards.
• Coordinate administrative support for state hearings and related documentation.

Education

High school diploma or equivalent

Tools

GARS system

Microsoft Office

Job description

Position Information:

• Department: Grievance & Appeals
• Salary Grade: 302 - $49,754 - $69,655 ($23.92 - $33.4880)
• Work Arrangement: Full Office
• Work Schedule: Monday through Friday, 8:00 AM to 5:00 PM
• Expected Assignment Duration: Up to six (6) months

Duties & Responsibilities:

• 80% - Program Support
  • Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
  • Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
  • Serves as the point of contact within or outside CalOptima Health for inquiries related to grievances and appeals.
  • Monitors incoming complaints via the Customer Service system routing, interdepartmental referral, mail, telephone, fax or via email from the website for members and providers.
  • Monitors inquiry requests from the Department of Managed Health Care (DMHC), Medicare Complaint Tracking Module (CTM) from the Centers for Medicare Medicaid Services (CMS), Medicare Quality Improvement Organization (QIO) and the State Hearing Office from Department of Social Services (DSS).
  • Responds to DMHC requests for information in a timely manner.
  • Sets up complaint case files, enters cases in the GARS system with accurate classification and category types and assigns them to appropriate staff.
• 15% - Administrative Support
  • Works with internal and external departments and providers in gathering supporting information relevant to the case.
  • Generates acknowledgment letters for all lines of business per department and regulatory standards.
  • Assists in the development of departmental forms and intake processes.
  • Coordinates administrative support for state hearings, serves as a contact with DSS for incoming cases, enters cases in the GARS system, creates electronic files and routes the scanned documents to designated staff and fax required state hearing documentation to the local hearing office as necessary.
• 5% - Other
  • Completes other projects and duties as assigned.

Minimum Qualifications:

• High school diploma or equivalent required PLUS 1 year of experience in appeal and grievance guidelines, Medi-Cal/Medicaid or Medicare programs 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.

Preferred Qualifications:

• Bilingual in English and in one of CalOptima Health’s defined threshold languages (Arabic, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese).

Required Licensure / Certifications:

• N/A

Knowledge & Abilities:

• 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.

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

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.

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.