Grievance Resolution Specialist
Company: Kinetic Personnel Group Inc.
Location: Orange
Posted on: April 28, 2024
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Job Description:
Kinetic Personnel Group is currently recruiting for a Grievance
Resolution Specialist for a Public Health Agency (government
entity). This position will be based in Orange County. This 3
billion-dollar a year government public agency is renowned for its
work in the community and being a great place to work.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.*Job duties:** 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 companys Healths
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 company Health
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.* 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 company Healths 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.*Requirements:** High School diploma or equivalent
required. (Associates degree preferred)* 1 year of experience in
any of the following areas: Grievances and Appeals, Claims,
Regulatory Compliance, Customer Service, or related fields
required.* Managed Care industry, health care, Medi-Cal/Medicaid,
and Medicare processes.* An equivalent combination of education and
experience sufficient to successfully perform the essential duties
of the position such as those listed above is also qualifying.*
Bilingual in English and in one of companys Health's defined
threshold languages (Arabic, Farsi, Chinese, Korean, Spanish,
Vietnamese) preferred.* Appeals and Grievances operating procedures
and processes strongly preferred.Tracking CodeRTF 2157Job Types:
Full-time, TemporaryPay: $20.00 - $29.00 per hourExpected hours: 40
per weekBenefits:* 401(k)* Dental insurance* Health insurance*
Vision insuranceExperience level:* 2 yearsShift:* 8 hour shift* Day
shiftWeekly day range:* Monday to FridayWork setting:* In-person*
OfficeEducation:* High school or equivalent (Required)Experience:*
Grievance and Appeals: 1 year (Required)Work Location: In personby
Jobble
Keywords: Kinetic Personnel Group Inc., Lake Elsinore , Grievance Resolution Specialist, Other , Orange, California
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