Senior Grievance & Appeals Specialist

Gold Coast Health Plan will not sponsor applicants for work visas.

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

POSITION SUMMARY

The Gold Coast Health Plan (GCHP) Senior Grievance and Appeals Specialist (G&A), will perform all the duties of a Senior G&A Specialist which includes the resolution of member and provider complaints, grievances and appeals, as well as handling more complex grievance issues. The Senior G&A Specialist will ensure compliance with contractual obligations and regulatory requirements for the G&A function. The Senior G&A Specialist has frequent external contact with members and/or member representatives,  health care providers, organizations and regulators. The Senior G&A Specialist plays a key role in collaborating with internal contacts in Member Services, Network Operations, Claims, Pharmacy and Health Services as well as other resources to identify factors necessary for the optimal resolution of complaints.

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation,  each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statements

•    Handle more complex grievance issues. Handle cases for State Fair Hearings. 

•    Provide training to G&A and other GCHP staff.

•    Assist the G&A manager with work distribution and monitoring of inventory.

•    Review reports to identify trends, determine root causes and work with impacted area(s) to make changes. 

•    Attend Committee Meetings as a delegate when appropriate.

•    Develop and maintain adequate information systems to assure timely and effective data collection, summarization, integration, and reporting which includes, but not limited to, case creation and management and events/activity tracking.

•    Ensure compliance with Grievance Policies and timely case resolution.

•    Gather pertinent information regarding complaint, including, but not limited to, member or provider concern, supporting information related to initial decision, new information supporting complaint, supplemental information required to evaluate complaint and regulatory requirements.

•    Coordinate and/or participate, as needed, in case discussion with operational experts to achieve in a final case disposition. Meet performance measurement goals for Grievance and Appeals.

•    Assure adequate and timely communication within Grievance and Appeals and with other GCHP departments and external customers.

•    Initiate referrals to the Quality Improvement Department as indicated and facilitate response to members according to GCHP policy.

•    Attend meetings on issues related to case assignments.

•    Ensure the company is compliant with regulatory requirements. 

•    Other duties as assigned by management.

POSITION QUALIFICATIONS 

Competency Statements

•    Analytical Skills - Ability to use thinking and reasoning to solve a problem.

•    Business Acumen - Ability to grasp and understand business concepts and issues. 

•    Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.

•    Communication,  Oral - Ability to communicate effectively with others using the spoken word.

•    Communication,  Written - Ability to communicate in writing clearly and concisely.

•    Interpersonal  - Ability to get along well with a variety of personalities and individuals.

•    Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

SKILLS & ABILITIES

Education: 

High School Graduate or General Education Degree (GED): Required

Bachelor's Degree (four year college or technical school): Preferred

Experience: 

•    7+ plus years of experience in grievance and appeals experience in a managed care environment. 

•    Medi-Cal and Medicare experience preferred.

Computer Skills: Advanced computer skills that include MS Office products (Word, Excel, PowerPoint).

Certifications & Licenses: All licenses and certificates must be maintained as a condition of employment. Possession of, or ability to obtain, a valid appropriate California driver's license. Maintain a satisfactory driving record. 

Other Requirements: 

•    Assist in the creation of policies, procedures and workflows.

•    Communicate  effectively in writing, orally, and with others to assimilate, understand, and convey information, in a manner consistent with job functions.

•    Organize own work, set priorities, meet critical deadlines, and follow-up on assignments with a minimum of direction.

Maintain confidentiality regarding sensitive information.

•    Comprehend and interpret policies and regulations. Work in a team setting as well as independently.