Appeals & Grievances Specialist I - Solugenix Corporation

Appeals & Grievances Specialist I
Los Angeles, CA (Remote)
6-Month Contract
Job ID 24-09257

Solugenix is assisting a client, a prestigious health insurance company, in their search for an Appeals & Grievances Specialist I. This is a 6-month contract opportunity based out of Los Angeles, CA (Remote).

The Customer Solution Center Appeals and Grievances Specialist I primary function is to learn the specialty level appeals and grievances work supporting the higher-level position in this class series to ensure positive outcomes for members. It will support the Appeals and Grievances team to receive, investigate and resolve members and provide complaints and appeals and escalate complex issues or questions to the leadership team as appropriate.

Qualifications:

• At least 1 year of experience in Managed Care working with Medicare, Medi-Cal and other state-sponsored programs.
• Experience working with firm deadlines, able to interpret and apply regulations.
• Strong advocacy experience.
• Must be organized, detail-oriented, able to exercise strong independent judgment; possess conflict resolution and persuasion skills.
• A team player with excellent communication and presentation skills, able to work effectively with various internal departments/service areas, plan partners, participating provider groups and other external agencies.
• Proficient in MS Office applications including Word, Outlook and Excel.
• Ability to provide confidentiality and professional customer service skills.
• Ability to work under tight deadlines.
• Strong analytical, verbal, written and presentation skills, able to monitor and be compliant with strict regulatory deadlines.
• Knowledge of Medical terminology.

• The position is responsible for maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting noncompliance, and adhering to company policy and procedures, including accreditation requirements, and applicable federal, state and local laws and regulations.
• The primary function of this role is to learn the specialty level appeals and grievances work by resolving less complex cases to ensure positive outcomes for members.
• Supports the identification, investigation and resolve administrative complaints, and simple appeals while adhering to the Center for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MRMIB) and National Committee for Quality Assurance (NCQA) standards and regulations.
• Intakes, acknowledges, prepares case files and routes complaints to appropriate internal departments and external business partners for investigation and resolution, exercising strong independent judgment.
• Process assigned cases accurately and in a timely manner per instructions. Escalates complex issues or questions to leadership as appropriate.
• Actively participates in team meetings and provides recommendations for improvement as appropriate based on discoveries.
• Performs other duties as assigned.

Pay Range for CA, CO, IL, NJ, NY, WA, and DC: $26.56/hour to $33.19/hour. Starting rate of pay offered may vary depending on factors including but not limited to, position offered, location, education, training, and/or experience.

Solugenix will consider qualified applicants with a criminal history pursuant to the California Fair Chance Act and Ordinance. Applicants do not need to disclose their criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if we are concerned about conviction that is directly related to the job, applicants will be given the chance to explain the circumstances surrounding the conviction, provide mitigating evidence, or challenge the accuracy of the background report.

About the Client
Our client is one of the world's leading health insurance company based out of Los Angeles, CA.

About Solugenix
Solugenix is an information technology services company known for its deep experience and knowledge in providing comprehensive technology services, solutions, and talent support for companies around the world. The company offers a variety of cutting edge and talent support solutions to promote growth and cutting-edge advancement to our esteemed clients and candidates. We provide these talent support solutions on a contract, contract-to-hire, and direct hire basis. We also have additional resources from our staffing partners to ensure the right match and expertise for the best result.
For over 50 years, global and local brands have trusted Solugenix as an added resource and partner in taking steps to ensure their immediate and future success. In addition to generating ground-breaking, industry-defining solutions, Solugenix has been delivering the talent and support needed to make it happen. We are dedicated to partnering with clients and candidates whose core values also foster a culture of professionalism, teamwork, and integrity.