We are seeking for a Grievance Resolution Specialist that has experience managing care services( in network vs out of network services) for Orange, CA area!


Salary: $25 - $38.04 per hour


Gathers pertinent information regarding the grievances and appeals received, including, but not limited to, 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/or participates in case discussion with operational experts to result in a final case disposition as needed.


Evaluates case details, proposes recommendations, or makes decisions as applicable; ensures organization 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.


Initiates referrals to Quality Improvement department as applicable and facilitates responses to members according to policy.


Assists with Health Networks' compliance process.


Identifies trends and root cause of issues; proposes solutions or escalates ongoing issues to management.


Meets performance measurement goals for Grievance and Appeals Resolution Services.


Completes other projects and duties as assigned.


Experience & Education


High School diploma or equivalent required.


1 year of experience in any of the following areas: Grievances and Appeals, Claims, Regulatory Compliance, Customer Service, or related fields required.


An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying


Bilingual in English and in one of the defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).


All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance. For unincorporated Los Angeles county, to the extent our customers require a background check for certain positions, the Company faces a significant risk to its business operations and business reputation unless a review of criminal history is conducted for those specific job positions.