Customer Solution Center Appeals and Grievances Specialist III
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 Specialist III 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 CMS, DHCS, DMHC, MBMIB and NCQA regulatory requirements. The 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 responsible for monitoring the caseloads of the Grievance Specialists and ensuring timely and accurate closure of grievances to meet regulatory requirements. The position is also responsible for overseeing the case resolution process and conducting quality checks to ensure that resolutions meet regulatory and internal requirements. 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.
Contacts members as needed to investigate, coordinate care and support resolutions for clinical and non-clinical cases.
Identifies, investigates, and resolves administrative complaints, complex provider appeals and State Fair Hearing cases adhering to Centers for Medicare and Medicaid Services(CMS), California Department of Health Care Services (DHCS), California Department of Managed Health Care (DMHC), MRMIB and National Committee for Quality Assurance (NCQA) standards and regulations.
Intakes, acknowledges, prepares case files and routes complaints to appropriate internal department for investigation and resolution, exercising strong independent judgment. Oversees members' case files in the applicable database/system to ensure that files are accurate and complete. Oversees caseloads for assigned specialists and provides coverage for assigned specialists who are absent.
Monitors daily/weekly/monthly grievance reports to ensure timeliness of case closures to meet internal and external reporting requirements. Prepares and analyzes 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.
Performs outreach to internal departments, Plan Partners, IPA/PPGs, facilities and vendors to gather information, medical records and other documentation as needed by nurse and in compliance with PP/PPG contracts.
Completes non-clinical aspects of Clinical Grievance Resolution Letter using appropriate template for type of case and LOB. Provides completed letter with attachments for nurse to approve. Arranges for translation of letter, if required, in time to meet regulatory timelines. Mails letter using department protocols.
Performs other duties as assigned.
In lieu of degree, equivalent education and/or experience may be considered.
Bachelor's Degree in Health Administration
At least 4 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.
Knowledge of Medical terminology and strong advocacy experience.
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.
Strong knowledge of regulatory standards and claims processing.
Strong analytical, verbal, written and presentation skills.
Able to monitor and be compliant with strict regulatory deadlines.
Proficient in Access, Visio.
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)