CalOptima Health is seeking a highly motivated an experienced TEMPORARY - Grievance Resolution Specialist (Provider Resolution) to join our team. The Grievance Resolution Specialist (Provider Resolution) will coordinate the Grievance and Appeal resolution process, respond to verbal and written Grievances and Appeals from members and providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, pharmacy and vision decisions. The incumbent will have frequent external contact with members and families, health care providers, health networks, third party administrators and regulators. The incumbent will collaborate with internal departments such as Customer Service, Provider Relations, Pharmacy and Medical Management to identify factors necessary for the optimal resolution of Grievances and Appeals.
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).
Required Licensure / Certifications:
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.