Grievance Resolution Specialist - Impresiv Health
Orange, CA 92868
About the Job
Title: Grievance Resolution Specialist
Duration: up to 6 months
Compensation: $25.87-$38.81/hour
Description: The Grievance Resolution Specialist coordinates the Grievance and Appeal resolution process, responds to verbal and written Grievances and Appeals from members and/or providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, and pharmacy and vision decisions. The incumbent has frequent external contact with members and families, healthcare providers, health networks, third-party administrators, and regulators. The incumbent collaborates with internal departments such as Customer Service, Provider Operations, Pharmacy, and Medical Management to identify factors necessary for the optimal resolution of Grievances and Appeals.
What You Will Do:
You Will Be Successful If:
What You Will Bring:
About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That's Impresiv!
Duration: up to 6 months
Compensation: $25.87-$38.81/hour
Description: The Grievance Resolution Specialist coordinates the Grievance and Appeal resolution process, responds to verbal and written Grievances and Appeals from members and/or providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, and pharmacy and vision decisions. The incumbent has frequent external contact with members and families, healthcare providers, health networks, third-party administrators, and regulators. The incumbent collaborates with internal departments such as Customer Service, Provider Operations, Pharmacy, and Medical Management to identify factors necessary for the optimal resolution of Grievances and Appeals.
What You Will Do:
- 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 the Health Plan'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, but not limited to, 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/or participates in case discussion with operational experts to result in a final case disposition as needed.
- Evaluates case details, proposes recommendations, or makes decisions as applicable; ensures organization 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.
- Initiates referrals to Quality Improvement department as applicable and facilitates responses to members according to Health Plan policy.
- Assists with Health Networks' compliance process.
- Identifies trends and root cause of issues; proposes solutions or escalates ongoing issues to management.
- Meets performance measurement goals for Grievance and Appeals Resolution Services.
- Completes other projects and duties as assigned.
You Will Be Successful If:
- Exercise discretion in processing confidential information.
- Identify critical issues and make recommendations or decisions by using critical thinking skills.
- Document and present case research findings and formulate resolution letters.
- Communicate clearly and concisely both orally and in writing.
- Establish and maintain effective working relationships with the Health Plan's leadership and staff.
- 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.
What You Will Bring:
- High school diploma or equivalent required, associate's degree preferred
- 1+ year of experience in any of the following areas: Grievances and Appeals, Claims, Regulatory Compliance, Customer Service, or related fields required
- Experience in healthcare practice standards, for government and commercial plans
- Experience in the managed care industry, health care, Medi-Cal/Medicaid and Medicare processes
- Knowledge of appeals and grievance operation procedures and processes
- Knowledge of state and federal regulations in the healthcare industry
- Bilingual in English and one of the following languages preferred: Arabic, Chinese, Farsi, Korean, Spanish, Vietnamese
About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That's Impresiv!
Source : Impresiv Health