Job Description
Johnson Service Group (JSG) is seeking a Bilingual Grievance Resolution Specialist- Healthcare in Orange, CA. This is an on-site position.
Work Schedule: Monday-Friday 8am- 5pm
Hourly pay: $26- $38.00per hour
Bilingual in English and in one of company defined threshold languages (Arabic, Farsi, Chinese, Korean, Russian, Spanish, Vietnamese) Preferred.
Duties & Responsibilities:
Work Schedule: Monday-Friday 8am- 5pm
Hourly pay: $26- $38.00per hour
Bilingual in English and in one of company defined threshold languages (Arabic, Farsi, Chinese, Korean, Russian, Spanish, Vietnamese) Preferred.
Duties & Responsibilities:
- 90% - Program Support
- 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 company systems and 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 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 participates in case discussions with operational experts to result in a final case disposition as needed.
- Evaluates case details, proposes recommendations or makes decisions as applicable and ensures the organization’s 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.
- Contacts appropriate parties to request and obtain missing information and supporting documentation or provides education.
- Reads and interprets provider contracts, Division of Financial Responsibility (DOFR), policies, procedures and instructions.
- Responds to routine provider inquiries via phone, assisting with provider appeals resolution inquiries.
- Assists with the health networks’ compliance process.
- Identifies trends and root causes of issues, proposes solutions or escalates ongoing issues to management.
- Meets performance measurement goals for Grievance and Appeals Resolution Services.
- 10% - Other
- Completes other projects and duties as assigned.
- High school diploma or equivalent PLUS 1 year of experience with Provider Dispute Resolution in Medicare and Medi-Cal in professional, institutional, outpatient, ancillary, coordination of benefits and government cases 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.
- 1 year of experience with Medicare or Medi-Cal provider appeals and denials process required.
- 1 year of experience in any of the following areas: Grievances and Appeals, Claims Administration, Regulatory Compliance, Customer Service or related field required.
- Associate degree in business, health care administration or related field.
- Experience in health care practice standards, for both government and commercial plans.
- Bilingual in English and in one of company defined threshold languages (Arabic, Farsi, Chinese, Korean, Russian, Spanish, Vietnamese).
Numbers & Facts
| Location | Orange, CA |
| Industry | Staffing/Employment Agencies |
| Salary | $26 Per Hour |
| Company Size | 1,000 to 1,499 employees |
| Year Founded | 1984 |
| Website | https://www.jsginc.com/ |
About Company
At JSG, We Understand People
It is our mission to empower people, help our clients reach their goals, and hire motivated individuals.
Since our start in 1984, we’ve worked hard to establish our present position as the most effective cross-industry staffing and consulting solution available.
Headquartered in Chicago, IL with local offices throughout the United States and Canada, JSG proudly serves a diverse range of industries with the right solutions to help clients reach their company goals. Our client-centric approach enables us to create personalized solutions for businesses in need of top-tier talent. Our dedication doesn’t stop at our clients. We strive to connect candidates with opportunities that match their skills and goals. More than just a go-between, we are a dependable bridge, uniting top talent with suitable opportunities, facilitating shared opportunities and growth.