Grievance Resolution Specialist - Sunshine Enterprise USA LLC

Grievance Resolution Specialist

Company Summary: Our client is seeking an experienced digital communication specialist in a lead position, who will work closely with staff to ensure effective communication with members and other audiences about programs and activities.

Position Summary: The ideal candidate shall hold the relevant bachelor’s degree and 5 years of experience in professional editing and writing.

Work Duration: Up to 6 months

Job Type: On-site

Position Responsibilities

• Gathers pertinent information regarding the grievances and appeals received, including 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 participates in case discussions with operational experts to result in a final case disposition as needed.
• Evaluates case details, proposes recommendations, or makes decisions as applicable, ensures the organization’s 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 the Quality Improvement department as applicable and facilitates responses to members according to CalOptima Health policy.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Assists with health networks’ compliance process. Meets performance measurement goals for Grievance and Appeals Resolution Services (GARS).
• Identifies trends and root cause of issues, proposes solutions, or escalates ongoing issues to management.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Assists with health networks’ compliance process.
• Meets performance measurement goals for Grievance and Appeals Resolution Services (GARS).
• Identifies trends and root cause of issues, proposes solutions, or escalates ongoing issues to management.
• Completes other projects and duties as assigned

Experience & Education

• Associate’s degree in business, health care administration or related field required.
• 1 year of experience in any of the following areas: Grievances and Appeals, Claims, Regulatory Compliance, Customer Service or related field required.
• Experience in health care practice standards for both government and commercial plans strongly preferred.
• Bilingual in English and one of the following languages: Arabic, Farsi, Chinese, Korean, Spanish, or Vietnamese
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

Necessary Attributes:

• Develop rapport and establish and maintain effective working relationships with leadership and staff and external contacts at all levels and with diverse backgrounds
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events
• Organize, be analytical, problem-solve and possess project management skills
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees/coalitions.
• 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

Please see HR for information on physical demands and work environment of this job.

Sunshine Enterprise USA is an “Equal Opportunity Employer—Minorities, Females, Veterans and Disabled Persons”