- Medical, Dental and Vision
- Wellness Program
- Paid Sick Leave
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Appeals and Grievances Training Specialist
Found in: Appcast US C2 - 3 days ago
Mitchell Martin Inc. Los Angeles, United StatesJob Summary · The Customer Solutions Center Appeals and Grievances (A&G) Training Specialist II is primarily responsible for the overall training strategy across the department. This position designs and conducts training programs using established regulatory and departmental gui ...
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Grievance & Appeals Specialist
Found in: ZipRecruiter Standard US C2 - 3 days ago
Dental Health Services Long Beach, United StatesJob Description · Job DescriptionYou will contribute to the strength of our team approach to collaborative dental health. · Do you value making an impact and doing meaningful work? Are you ready to be a difference-maker at an established independent Employee-Owned specialized hea ...
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Customer Solution Center Appeals and Grievances Specialist II
Found in: Lensa US 4 C2 - 5 days ago
L.A. Care Health Plan Los Angeles, United StatesCustomer Solution Center Appeals and Grievances Specialist II · Job Category: Customer Service · Department: CSC Appeals & Grievances · Location: · Los Angeles, CA, US, 90017 · Position Type: Full Time · Requisition ID: 10996 · Salary Range: $60, Min.) - $75, Mid.) - $91, Max.) · ...
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Customer Solution Center Appeals and Grievances Specialist II
Found in: beBee S2 US - 1 week ago
L.A. Care Health Plan Los Angeles, United States Full timeSalary Range: $60, Min.) - $75, Mid.) - $91, Max.) · Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated ...
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Customer Solution Center Appeals and Grievances Specialist II
Found in: beBee S2 US - 1 week ago
L.A. Care Health Plan Los Angeles, United StatesSalary Range: $60, Min.) - $75, Mid.) - $91, Max.) · Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated ...
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Utilization Management/Appeals and Grievances Nurse Specialist RN II
Found in: Lensa US 4 C2 - 3 days ago
L.A. Care Health Plan Los Angeles, United StatesUtilization Management/Appeals and Grievances Nurse Specialist RN II · Job Category: Clinical · Department: CSC Appeals & Grievances · Location: · Los Angeles, CA, US, 90017 · Position Type: Full Time · Requisition ID: 10893 · Salary Range: $88, Min.) - $115, Mid.) - $142, Max.) ...
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Customer Solution Center Appeals and Grievances Training Specialist II
Found in: Lensa US 4 C2 - 1 day ago
L.A. Care Health Plan Los Angeles, United StatesPress Tab to Move to Skip to Content Link · Job Category: · Customer Service · Location: · Los Angeles, CA, US, 90017 · Position Type: · Full Time · Requisition ID: · 9802 · Salary Range: · $77, Min.) - $94, Mid.) - $123, Max.) · Established in 1997, L.A. Care Health Plan i ...
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Utilization Management/Appeals and Grievances Nurse Specialist RN II
Found in: beBee S2 US - 1 week ago
L.A. Care Health Plan Los Angeles, United StatesSalary Range: $88, Min.) - $115, Mid.) - $142, Max.) · Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operat ...
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Customer Solution Center Appeals and Grievances Training Specialist II
Found in: beBee S2 US - 1 week ago
L.A. Care Health Plan Los Angeles, United StatesSalary Range: $77, Min.) - $100, Mid.) - $123, Max.) · Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operat ...
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Customer Solution Center Appeals and Grievances Quality Auditing Specialist II
Found in: beBee S2 US - 4 days ago
L.A. Care Health Plan Los Angeles, United States Full timeSalary Range: $67, Min.) - $87, Mid.) - $107, Max.) · Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated ...
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Customer Solution Center Appeals and Grievances Quality Auditing Specialist II
Found in: beBee S2 US - 2 weeks ago
L.A. Care Health Plan Los Angeles, United StatesSalary Range: $67, Min.) - $87, Mid.) - $107, Max.) · Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operate ...
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Customer Solution Center Appeals and Grievances Quality Auditing Specialist II
Found in: beBee S2 US - 1 week ago
L.A. Care Health Plan Los Angeles, United StatesSalary Range: $67, Min.) - $87, Mid.) - $107, Max.) · Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operate ...
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Grievance And Appeals Nurse Specialist
Found in: beBee S2 US - 2 weeks ago
V Group Inc Orange, United StatesJob Title: Grievance and Appeals Nurse SpecialistCalOptima Health is seeking a highly motivated an experienced TEMP - Grievance & Appeals Nurse Specialist to join our team.The Grievance and Appeals Nurse Specialist participates in managing CalOptima Healths medical appeals and st ...
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Labor Relations Specialist
Found in: Lensa US 4 C2 - 5 days ago
University of California Los Angeles, United StatesAs our Labor Relations Specialist, you will establish and maintain satisfactory labor-management relations, including monitoring and ensuring adherence to contract provisions, participating in negotiating sessions, and addressing grievances and questions of a specific group of un ...
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Senior Employee and Labor Relations Specialist
Found in: Lensa US 4 C2 - 2 days ago
Los Angeles Community College District Office Los Angeles, United StatesDefinition · Plans, organizes, and supervises the day-to-day activities of a small unit engaged in employee and labor relations activities involving disciplinary actions, grievances, appeals, complaints, contract negotiations, and other related areas; personally performs the mor ...
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Quality Compliance Nurse and Compliance Coordinator
Found in: Lensa US 4 C2 - 3 days ago
Preferred IPA of California Los Angeles, United StatesJob Description · Job Description · Openings for both a Quality Compliance Nurse and a Compliance Coordinator. · QUALITY COMPLIANCE NURSE · PURPOSE: · The Quality and Compliance Nurse is responsible for working with the Medical Director, the VP of Clinical Policy, the QM Commi ...
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Area Business Specialist, Immunology
Found in: One Red Cent US C2 - 3 days ago
Disability Solutions Los Angeles, United StatesJanssen Biotech, Inc., a member of Johnson & Johnson's Family of Companies, is recruiting for an Area Business Specialist, Immunology for the Los Angeles, CA territory. · At Johnson & Johnson, we believe health is everything. Our strength in healthcare innovation empowers us to ...
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Healthcare Audit Specialist
Found in: Lensa US 4 C2 - 1 day ago
Mitchell Martin Los Angeles, United StatesHealthCare Audit Specialist · Full time · Location: Los Angeles, CA - Hybrid · Job Summary · The Customer Solution Center Audit Readiness Specialist II is responsible for the execution, oversight, and monitoring of the guidelines and protocols to ensure readiness for all regula ...
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Associate Medical Director
Found in: ZipRecruiter Standard US C2 - 3 days ago
MedPOINT Management Los Angeles, United StatesJob Description · Job Description MedPOINT Management (MPM) · Department: Utilization Management (UM) · Title Associate Medical Director · Summary · The Associate Medical Director is responsible for providing medical interpretation and decisions about appropriateness of services ...
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quality management nurse specialist rn ii
Found in: Careerbuilder One Red US C2 - 3 days ago
L.A. Care Health Plan Los Angeles AFB, CA , USA, United StatesSalary Range: $88, Min.) - $115, Mid.) - $142, Max.) · Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operate ...
Customer Solution Center Appeals and Grievances Specialist II - Los Angeles, United States - L.A. Care Health Plan
Description
Salary Range: $60,778.00 (Min.) - $75,950.00 (Mid.) - $91,166.00 (Max.)
Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.
Mission: L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
As a condition of employment, L.A. Care requires a COVID-19 vaccine. This requirement includes our remote workforce. If you would like to request an exemption, L.A. Care has implemented a process to consider exemptions for documented medical conditions and sincerely held religious beliefs. L.A. Care will review all exemption requests prior to proceeding with the recruitment process.
Job Summary
The Customer Solution Center Appeals and Grievances (A&G) Specialist II will receive, investigate and resolve member and provider complaints and appeals exercising strong independent judgment. This position will provide resolution of complaints in compliance with Centers for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MBMIB) and National Committee for Quality Assurance (NCQA) regulatory requirements. This position reviews pre-service authorizations, concurrent and post-service (retroactive review) medical necessity; benefit coverage appeals and reconsiderations, and complex provider claim disputes. The position is further responsible for tracking, trending and reporting complaints and appeals, as well as participating in internal and external oversight activities.
The position is responsible for maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting noncompliance, adhering to company policy and procedures, including accreditation requirements, applicable federal, state and local laws and regulations.
Duties
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.
Duties Continued
Education Required
Associate's DegreeIn lieu of degree, equivalent education and/or experience may be considered.
Education Preferred
Bachelor's Degree
Experience
Required:
At least 2 years experience in Managed Care with specific experience in resolving member and provider complaint and appeals issues, including eligibility, access to care, claims, benefit, and quality of care concerns.
Experience working with firm deadlines, able to interpret and apply regulations.
At least 5 years experience in Managed Care working with Medicare, Medi-Cal and other State Sponsored programs.
Knowledge of Medical terminology and strong advocacy experience.
Skills
Required:
Must be organized, detail oriented, able to exercise strong independent judgment; poses conflict resolution and persuasion skills.
A team player with excellent communication and presentation skills, able to work effectively with various internal departments/service areas, plan partners, participating provider groups and other external agencies.
Proficient in MS Office applications, Word, Excel and Power Point.
Requires strong knowledge of regulatory standards and claims processing; strong analytical, oral, written and presentation skills, able to monitor and be compliant with strict regulatory deadlines.
Preferred:
Proficient in MS Office applications, Access, Visio.
Licenses/Certifications Required
Licenses/Certifications Preferred
Required Training
Additional Information
Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including
At L.A. Care, we value our team members' safety. In order to keep our work locations safe, each employee is required to self-screen for symptoms prior to entering any L.A. Care location each day. L.A. Care and all of its staff are required to comply with all state and local masking orders. Therefore, when on-site at any L.A. Care location, it's expected that all employees wear a mask in areas where physical distancing cannot be managed.
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