Department(s): Grievance & Appeals Resolution Services (GARS)
Reports to: Manager, Grievance & Appeals
FLSA status: Non-Exempt
Salary Grade: C – $19.7115 – $25.4808 ($41,000 – $53,000)
Job Summary
Under general supervision, the incumbent will assist with specialized services relevant to the Grievance & Appeals Resolution Services (GARS) department. The incumbent will exercise discretion and judgment and may assist in coordinating a function for the program assigned. Primary responsibilities include monitoring the GARS mailbox, fax, mail, and processing appeals and grievances for assignment to key staff within the required timeframe.
Position Responsibilities:
Serves as point of contact within, or outside CalOptima for inquiries related to grievances and appeals.
Monitors incoming complaints via the Customer Service system routing, interdepartmental referral, mail, telephone, fax, or via email from the website for members and providers.
Monitors for inquiry requests from the Department of Managed Health Care (DMHC), Medicare Complaint Tracking Module (CTM) from the Centers for Medicare Medicaid Services (CMS), the Medicare Quality Improvement Organization (QIO) and the State Hearing Office from Department of Social Services (DSS).
Responds timely to the DMHC on requests for information.
Works with internal and external departments and providers in gathering supporting information relevant to the case.
Sets-up complaint case files, enters cases in the GARS system with accurate classification, and category types and assigns to appropriate staff.
Generates acknowledgement letters for all lines of business per department and regulatory
Assists in the development of departmental forms and intake process.
Coordinates administrative support for State Hearings including serving as contact with State Department Social Services for incoming cases, entering cases in the GARS system, creating electronic file, and routing the scanned documents to designated staff and faxing required State Hearing documentation to local hearing office as necessary.
Other projects and duties as assigned.
Possesses the Ability To:
Provide professional support to managers and staff in program to which
Work under general supervision to perform routine administrative and support activities.
Coordinate multiple administrative activities.
Work on specialized process or function to which assigned.
Communicate clearly and concisely, both verbally and in writing, with internal and external contacts.
Establish and maintain effective working relationships with CalOptima leadership and staff.
Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Experience and Education:
High school diploma or equivalent required.
1 year of experience in Claims Administration or Grievance and Appeals required.
Preferred Qualification:
Professional, institutional, and Medi-Cal / Medicare claims experience strongly preferred.
1 year of experience in appeal and grievance guidelines or Medi-Cal/Medicaid or Medicare programs preferred.
Bilingual in English and in one of CalOptima’s defined threshold language (Spanish, Vietnamese, Arabic, Farsi, Korean, Chinese) is preferred.
Knowledge of:
Services, policies, and general responsibilities of program to which assigned.
Practices and techniques required to function with professions working in assigned program.
Methods and techniques for organizing and implementing processes.
General information relevant to professional or administrative responsibilities in assigned program.
CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.
If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.
Job Location: Orange, California
Position Type:
To apply, visit https://jobs.silkroad.com/CalOptima/Careers/jobs/3462
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