Appeals and Grievances Specialist

Appeals and Grievances Specialist

Location: Los Angeles, CA

Onsite Flexibility: Hybrid

Contract Details

• Position Type: Contract
• Contract Duration: 3 months (extensions available)
• Pay Rate: $29.32 $36.00 / Hour (USD)
• Shift / Schedule: Days (1st Shift)
• Work Authorization: Applicants must be authorized to work for ANY employer in the U.S. We are unable to sponsor or take over sponsorship of an employment Visa at this time.

Job Summary

The Appeals and Grievances (A&G) Specialist 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 Centers for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MRMIB), and National Committee for Quality Assurance (NCQA) regulatory requirements. This 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 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.

Key Responsibilities

• Identifies, investigates, and resolves administrative complaints, complex provider appeals and State Fair Hearing adhering to CMS, DHCS, DMHC, MRMIB, and NCQA standards and regulations.
• Intakes, acknowledges, prepares case files, and routes complaints to appropriate internal department for investigation and resolution, exercising strong independent judgment.
• Ensures integrity of A&G database by thorough, timely, and accurate assignment of cases. Monitors closure of complaints and works with Quality Control Supervisor to resolve all database issues.
• Prepare and analyze 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.
• Perform other duties as assigned.

Required Skills

• Must be organized, detail oriented, able to exercise strong independent judgment; possesses 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 PowerPoint.
• Requires strong knowledge of regulatory standards and claims processing; strong analytical, oral, written, and presentation skills, able to monitor and be compliant with strict regulatory deadlines.
• Understanding of HIPAA and patient confidentiality.
• Strong organizational and time management skills.
• Excellent written and verbal communication.
• Ability to prioritize multiple cases while meeting regulatory deadlines.
• Attention to detail and documentation accuracy.
• Proficient in Microsoft Outlook, Word, Excel (sorting, filtering, basic formulas), and Teams.

Preferred Skills

• Proficient in Access and Visio.
• Experience with Medi-Cal.
• Experience with Medicare Advantage.
• Experience with commercial health insurance.
• Experience with appeals and grievance workflows.
• Experience with prior authorization processes.
• Experience with claims review.
• Experience with coordination of care.
• Experience with member and provider communications.

Education Requirements

• Associate's Degree required. In lieu of degree, equivalent education and/or experience may be considered.
• Bachelor's Degree preferred.

Required Experience

• At least 2 years of 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.
• At least 5 years of experience in Managed Care working with Medicare, Medi-Cal, and other State Sponsored programs.
• Knowledge of Medical terminology and strong advocacy experience.
• 2 3 years of experience in one or more of the following: health insurance, managed care, medical office, Utilization Management (UM), Case Management, Appeals & Grievances, or claims processing.

Benefits

• Medical, Vision, and Dental Insurance Plans
• 401k Retirement Fund

About the Client

This client is a not-for-profit healthcare organization dedicated to serving vulnerable and underserved communities throughout the Los Angeles area. The organization is committed to providing accessible, high-quality care and administrative services to its members, employing professionals across managed care, appeals and grievances, utilization management, claims processing, and member services functions.

About GTT

GTT is a minority-owned staffing firm and a subsidiary of Chenega Corporation, a Native American-owned company in Alaska. We highly value diverse and inclusive workplaces and support Fortune 500 organizations across banking, financial services, technology, life sciences, biotech, utilities, and retail sectors throughout the U.S. and Canada.

Job Number: 26-11623