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Grievance and Appeals Specialist- Healthcare
JSG (Johnson Service Group, Inc.)Orange, CA, United States3 days ago
Job type
- Full-time
Job descriptionBilingual in English and in one of company's defined threshold languages (Arabic, Chinese, Farsi, Korean, Spanish, Vietnamese). Develop rapport and establish and maintain effective working relationships with company leadership and staff and external contacts at all levels and with diverse backgrounds. Work independently and exercise sound judgment. Communicate clearly and concisely, both orally and in writing. Work a flexible schedule; available to participate in evening and weekend events. Organize, be analytical, problem-solve and possess project management skills. Work in a fast-paced environment and in an efficient manner. Manage multiple projects and identify opportunities for internal and external collaboration. Motivate and lead multi-program teams and external committees / coalitions. 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. 80% - Program Support 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. Serves as the point of contact within or outside company for inquiries related to grievances and appeals. Monitors incoming complaints via the Customer Service system routing, interdepartmental referral, mail, telephone, fax or via email from the website for members and providers. Monitors inquiry requests from the Department of Managed Health Care (DMHC), Medicare Complaint Tracking Module (CTM) from the Centers for Medicare Medicaid Services (CMS), Medicare Quality Improvement Organization (QIO) and the State Hearing Office from Department of Social Services (DSS). Responds to DMHC requests for information in a timely manner. Sets up complaint case files, enters cases in the GARS system with accurate classification and category types and assigns them to appropriate staff. 15% - Administrative Support Works with internal and external departments and providers in gathering supporting information relevant to the case. Generates acknowledgment letters for all lines of business per department and regulatory standards. Assists in the development of departmental forms and intake processes. Coordinates administrative support for state hearings, serves as a contact with DSS for incoming cases, enters cases in the GARS system, creates electronic files and routes the scanned documents to designated staff and fax required state hearing documentation to the local hearing office as necessary. 5% - Other Completes other projects and duties as assigned.
Johnson Service Group (JSG) is seeking a Healthcare Grievance and Appeals Resolution Specialist in Orange County California. This is an onsite position.
Work Schedule : Monday-Friday (8 : 00am- 5 : 00pm)
Pay range : $24.00- $33.00 per hour DOE
Minimum Qualifications
- High School diploma or equivalent required PLUS 1 year of experience in appeal and grievance guidelines or Medi-Cal / Medicaid or Medicare programs required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
Preferred Qualifications :
Knowledge & Abilities :
Duties & Responsibilities :
JSG offers medical, dental, vision, life insurance options, short-term disability, 401(k), weekly pay, and more. Johnson Service Group (JSG) is an Equal Opportunity Employer. JSG provides equal employment opportunities to all applicants and employees without regard to race, color, religion, sex, age, sexual orientation, gender identity, national origin, disability, marital status, protected veteran status, or any other characteristic protected by law. #D800
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Healthcare Specialist • Orange, CA, United States
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