Grievance & Appeals Specialist I

Come Grow With Us
At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges.

Working at Gold Coast Health Plan means working alongside a team of committed individuals who are reshaping the organization and redefining how the needs of the whole person - health, health care, and social services and supports - are met. We are seeking collaborators, innovators, and those who are driven to be their very best.

If you are looking for a career of purpose and are passionate about having an impact on society's health care challenges, then Gold Coast Health Plan is where you should be. Here, you will be challenged and rewarded in equal measure.

About this role:

Reasonable Accommodations Statement
To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

Job Function & Responsibilities
* Develop and maintain adequate information systems to assure timely and effective data Develop and maintain adequate information systems to assure timely and effective data collection, summarization, integration, and reporting which includes, but not limited to, case creation and management and events/activity tracking.
* Ensure compliance with Grievance Policies and timely case resolution.
* Gather pertinent information regarding complaint, including, but not limited to, member or provider concern, supporting information related to initial decision, new information supporting complaint, supplemental information required to evaluate complaint and regulatory requirements.
* Coordinate and/or participate, as needed, in case discussion with operational experts to achieve in a final case disposition.
* Meet performance measurement goals for Grievance and Appeals.
* Assure adequate and timely communication within Grievance and Appeals and with other GCHP departments and external customers.
* Initiate referrals to the Quality Improvement Department as indicated and facilitate response to members according to GCHP policy.
* Attend meetings on issues related to case assignments.
* Ensure the company is compliant with regulatory requirements.
* Any other duties as assigned

Position Qualifications

Skills & Abilities

Education:
* High School Graduate or General Education Degree (GED): Required
* Bachelor's degree preferred
Equivalent In lieu of degree: Will accept any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.

Experience:
* 3-5 years of experience in a managed care environment, preferably with grievance and
* appeals or claims processing background.
* Medi-Cal/Medicaid managed care and Medicare experience strongly desired.

Computer Skills:
* Computer proficiency included in MS Office programs.

Other Requirements:
Knowledge of:
* Grievance and appeals rules and processes.
* Principles and practices of managed care.
* Medi-Cal/Medicare eligibility and benefits.
* MS Word, Excel and Outlook required.

Ability to:
* Communicate effectively in writing, orally, and with others to assimilate, understand, and convey information, in a manner consistent with job functions.
* Organize own work, set priorities, meet critical deadlines, and follow-up on assignments with a minimum of direction.
* Maintain confidentiality regarding sensitive information.
* Comprehend and interpret policies and regulations.
* Work in a team setting as well as independently.

Certifications & Licenses: If travel is required include: A valid and current Driver's License, Auto Insurance, and professional licensure(s)

Competency Statements
* Business Acumen - Ability to grasp and understand business concepts and issues.
* Communication, Oral - Ability to communicate effectively with others using the spoken word.
* Communication, Written - Ability to communicate in writing clearly and concisely.
* Research Skills - Ability to design and conduct a systematic, objective, and critical investigation.
* Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

The estimated pay range for the position is:

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.