Appeals and Grievances Specialist II

L.A. Care Health Plan•Los Angeles, CA

1d•$60,778 - $91,166•Hybrid

About The Position

The Appeals and Grievances (A&G) Specialist II receives, investigates, and resolves member and provider complaints and appeals, exercising strong independent judgment. The role resolves complaints in compliance with requirements from CMS, DHCS, DMHC, MRMIB, and NCQA. It reviews pre-service authorizations, concurrent and post-service (retroactive) medical necessity, benefit coverage appeals and reconsiderations, and complex provider claim disputes. The Specialist also tracks, trends, and reports complaints and appeals and participates in internal and external oversight activities. The position is responsible for maintaining privacy and confidentiality, protecting organizational assets, acting ethically and with integrity, reporting noncompliance, and following company policies and procedures, accreditation requirements, and applicable laws and regulations. The role requires handling various caseloads and adapting to changing priorities, including redistributed assignments, team projects, and other priorities as assigned.

Requirements

At least 2 years of Managed Care experience, specifically resolving member and provider complaint and appeal issues involving eligibility, access to care, claims, benefits, and quality-of-care concerns.
At least 5 years of Managed Care experience working with Medicare, Medi-Cal, and other State Sponsored programs.
Experience working with firm deadlines and the ability to interpret and apply regulations.
Knowledge of medical terminology and strong advocacy experience.
Organized and detail-oriented, with the ability to exercise strong independent judgment and use conflict-resolution and persuasion skills.
Team player with excellent communication and presentation skills; able to work effectively with internal departments and service areas, plan partners, participating provider groups, and external agencies.
Proficiency in MS Office applications, including Word, Excel, and PowerPoint.
Strong knowledge of regulatory standards and claims processing, with strong analytical, oral, written, and presentation skills and the ability to meet strict regulatory deadlines.
Associate's degree; equivalent education and/or experience may be considered in lieu of a degree.

Nice To Haves

Bachelor's degree.
Proficiency in Access and Visio.

Responsibilities

Identify, investigate, and resolve administrative complaints, complex provider appeals, and State Fair Hearings in accordance with CMS, DHCS, DMHC, MRMIB, and NCQA standards and regulations.
Intake and acknowledge complaints, prepare case files, and route complaints to the appropriate internal department for investigation and resolution.
Ensure the integrity of the A&G database through thorough, timely, and accurate case assignment.
Monitor complaint closures and work with the Quality Control Supervisor to resolve database issues.
Prepare and analyze monthly appeal and grievance reports for internal and external reporting requirements.
Participate in internal and external oversight activities, inter-rater reliability reviews, and focused audits; recommend opportunities for improvement.
Maintain privacy and confidentiality, protect organizational assets, act with ethics and integrity, report noncompliance, and adhere to policies, accreditation requirements, and applicable laws and regulations.
Perform other duties as assigned.