Customer Solution Center Appeals and Grievances Coordinator I
CSC Appeals & Grievance
Los Angeles, CA, US, 90017
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.
The Customer Solution Center Appeals and Grievances Coordinator I supports the Customer Solution Center Appeals & Grievance Specialists by handling the administrative functions of the care management/continuity of care process including intake, logging, tracking and status follow-up.
This position collects information required by clinical staff to render decisions, assists the Customer Solution Center Appeals & Grievance Manager and Director in meeting regulatory timelines by maintaining an accurate database inventory of care management and continuity of care cases, and preparing monthly activity reports.
In addition, the position performs data entry and processing of health risk assessments in the system, maintains confidentiality when communicating member information, and assists with the communication and coordination between programs. Prepares template determination/education letters for members and providers, with other duties as assigned.
Provide non-clinical support to the Customer Solution Center Appeals and Grievance Specialists for L. A. Care's Medicare Advantage program. This includes the technical aspects of the time sensitive processes for initiating cases, managing referral documentation, entering pre-certification/continued authorizations, identifying and responding to urgency of the request, appropriate documentation, case routing & tracking, routing of information, performing computer data input, faxing, filing of confidential member information, and maintaining logs of activity, etc.). (40%)
Assist in the telephonic outreach calls to members identified during health risk assessments as in needed of care coordination assistance. Consist of follow up calls to members to administer screening or obtaining clarification on initial responses. (25%)
Under the supervision of the Appeals and Grievance Manager, assist with soliciting non-clinical information from Participating Physical Group (PPG) and specialist concerning follow care related to care management. (15%)
Maintain the monthly reporting responsibilities, Appeals and Grievance reporting to Department Director, ongoing referrals and authorizations for members in complex care management. (5%)
Accurately maintain an updated log of L.A. Care members identified as SPD or eligible with CCS cases. If members become ineligible with L.A Care or a specific program members are referred to Member Services for transition to other applicable programs". (5%)
Perform other duties as assigned. (10%)
High School Diploma/or High School Equivalency Certificate
At least 0-6 months of experience in Medi-Cal managed care authorization processes and/or as a Medical Assistant.
Knowledge of medical terminology and ICD-10 and CPT codes.
Strong verbal and written communication skills.
Proficiency with Microsoft Word, Excel, and Access.
Excellent organizational, interpersonal and time management skills.
Must be detail-oriented and an enthusiastic team player.
Knowledge of MHC computer system a plus.
Bilingual in one of L.A. Care Health Plan's threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.
Certified Medical Assistant (CMA)
L.A. Care offers a wide range of benefits including
+ Paid Time Off (PTO)
+ Tuition Reimbursement
+ Retirement Plans
+ Medical, Dental and Vision
+ Wellness Program
+ Volunteer Time Off (VTO)