Appeals & Grievances Specialist II - Solugenix Corporation

Appeals & Grievances Specialist II
Los Angeles, CA (Remote)
6-Month Contract
Job ID 24-09258

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

The Customer Solution Center Appeals and Grievances (A&G) Specialist II will receive, investigate, and resolve member and provider complaints and appeals exercising strong independent judgment. This position will provide resolution of complaints in compliance with the Centers for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MBMIB), and National Committee for Quality Assurance (NCQA) regulatory requirements. This position reviews pre-service authorizations, concurrent and post-service (retroactive review) medical necessity; benefit coverage appeals and reconsiderations, and complex provider claim disputes. The position is further responsible for tracking, trending, and reporting complaints and appeals, as well as participating in internal and external oversight activities.
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.

Qualifications Required:

• Associate's degree.
• In lieu of a degree, equivalent education and/or experience may be considered.
• Bachelor's Degree – Preferred.
• At least 2 years of experience in Managed Care with specific experience in resolving member and provider complaints and appeals issues, including eligibility, access to care, claims, benefits, and quality of care concerns.
• Experience working with firm deadlines, able to interpret and apply regulations.
• At least 5 years of experience in Managed Care working with Medicare, Medi-Cal, and other state-sponsored programs.
• Knowledge of Medical terminology and strong advocacy experience.

• Identifies, investigates, and resolves administrative complaints, complex provider appeals, and State Fair Hearing adhering to CMS, DHCS, DMHC, MRMIB, and NCQA standards and regulations.
• Intakes, acknowledges, prepares case files, and routes complaints to the appropriate internal department for investigation and resolution, exercising strong independent judgment.
• Ensures integrity of the A&G database by thorough, timely, and accurate assignment of cases. Monitors closure of complaints and works with the Quality Control Supervisor to resolve all database issues.
• Prepare and analyze monthly appeal and grievance reports to meet internal and external reporting requirements.
• Participates in internal and external oversight activities, inter-rater reliability reviews, and focused audits. Recommends opportunities for improvement
• Perform other duties as assigned.

• 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, Word, Excel, and Power Point.
• Requires strong knowledge of regulatory standards and claims processing; strong analytical, oral, written, and presentation skills, able to monitor and be compliant with strict regulatory deadlines.

Preferred Skills:
Proficient in MS Office applications, Access, Visio.

Pay Range for CA, CO, IL, NJ, NY, WA, and DC: $29.22/hour to $36.51/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.