Analysis Skills, Artificial Intelligence (AI), Case Management, Communication Skills, Consulting, Content Management Systems (CMS), Documentation, Employee Benefits, Establish Priorities, Health Insurance, Health Plan, Healthcare, Insurance Claims, Maintain Compliance, Microsoft Exchange Server, National Committee for Quality Assurance (NCQA), Policy Development, Process Improvement, Quality Assurance, Quality Metrics, Regulations, Regulatory Compliance, Resolve Customer Issues, Short Messaging Service (SMS), Spreadsheets, Team Player, Time Management, Trend Analysis, Typing, Writing Skills
Immediate need for a talented Appeals & Grievance Manager. This is a 12 months contract opportunity with long-term potential and is located in Corona, CA(Remote). Please review the job description below and contact me ASAP if you are interested.
Job ID: 26-17160
Pay Range: $30/hr - $32/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).
Key Responsibilities:
- Resolve member grievance and appeals cases, with a focus on healthcare coverage issues.
- Investigated and resolved member and provider grievances and appeals in alignment with CMS, DMHC, and NCQA regulatory guidelines.
- Drafted and issued clear, accurate, and timely written determinations, ensuring compliance with state and federal requirements.
- Collaborated with compliance, legal, and clinical teams to ensure all case reviews met regulatory and quality standards.
- Prioritized and managed a high-volume caseload, consistently meeting strict regulatory timelines for resolution.
- Maintained detailed documentation of case activities to support audits, reporting, and quality assurance reviews.
- Identified trends in appeal outcomes and provided feedback to improve policies, processes, and compliance performance.
Key Requirements and Technology Experience:
- Key skills; Experience in Appeals & Grievances
- Experience in Case Management
- 5 years of recent experience in:
- Healthcare case management
- Grievance and appeals handling
- Letter Writing
- Strong analytical and critical thinking abilities
- Excellent documentation and written communication skills
- Strong interpersonal and listening skills; able to work with real people in real situations
- Comfortable with member-facing roles and handling complaint resolution
- Must be a team player and adaptable to change
- Knowledge of Healthcare Exchange programs
- Experience working with Excel and spreadsheets (Intermediate level preferred)
- Typing speed of 30 WPM
- Previous experience in healthcare insurance and claims resolution
Our client is a leading Healthcare Industry, and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.
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