Job Description

Position: Grievance Resolution Specialist (Provider Resolution)

Work Arrangement: Full Office

Work Schedule: Monday to Friday (8:00 a.m. to 5:00 p.m.)

Position type: Contract

Duties & Responsibilities:

95% - 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.
• Maintains adequate information in CalOptima Health’s systems; ensures data collection, summarization, integration and reporting which includes case creation and management and events/activity tracking.
• Gathers pertinent information regarding the grievances and appeals received, including member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal or supplemental information required to evaluate grievances and appeals within regulatory requirements.
• Coordinates and participates in case discussions with operational experts to result in a final case disposition as needed.
• Evaluates case details, proposes recommendations or makes decisions as applicable and ensures the organization’s decision is implemented according to the Grievance and Appeals policies and case resolution.
• Develops resolution letters and correspondence to members and providers.
• Communicates with internal and external customers to ensure timely review and resolution of grievances or appeals.
• Contacts appropriate parties to request and obtain missing information and supporting documentation or provides education.
• Reads and interprets provider contracts, Division of Financial Responsibility (DOFR), policies, procedures and instructions.
• Responds to routine provider inquiries via phone, assisting with provider appeals resolution inquiries.
• Assists with the health networks’ compliance process.
• Identifies trends and root causes of issues, proposes solutions or escalates ongoing issues to management.
• Meets performance measurement goals for Grievance and Appeals Resolution Services.
• 5% - Completes other projects and duties as assigned.

Minimum Qualifications:

• High school diploma or equivalent PLUS 1 year of experience with Provider Dispute Resolution (PDR) in Medicare and Medi-Cal in professional, institutional, outpatient, ancillary, coordination of benefits and government cases 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.
• 1 year of experience with Medicare or Medi-Cal provider appeals and denials process required.
• 1 year of experience in any of the following areas: Grievances and Appeals, Claims Administration, Regulatory Compliance, Customer Service or related field required.

Preferred Qualifications:

• Associate degree in business, health care administration or related field.
• Experience in health care practice standards, for both government and commercial plans.
• Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).

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.

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