Program Assistant - Grievance and Appeals - SUNSHINE ENTERPRISE USA LLC

Job Summary: Under general supervision, the Program Assistant will assist with specialized services relevant to the Grievance and Appeals Resolution Services (GARS) department. The incumbent will work independently, exercising discretion and judgment, and may assist in coordinating a function for the program assigned. The incumbent’s primary responsibilities will include monitoring the GARS member and provider mailbox, fax, mail, and processing appeals and grievances for assignment to key staff within the required timeframe.

Position Responsibilities

• Serves as point of contact 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 to DMHC requests for information on a timely manner.
  
• 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 standards.
  
• Assists in the development of departmental forms and intake process.
  
• Coordinates administrative support for state hearings including serving as contact with DSS 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.
  
• Provide professional support to supervisors and staff in program to which assigned.
  
• Coordinate multiple administrative activities.
  
• Work on specialized process or function to which assigned.
  
• Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment
  

Experience & Education

• High School diploma required.
  
• 1 year of experience in appeal and grievance guidelines or Medi-Cal/Medicaid or Medicare programs required.
  
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
  

Preferred Qualifications

• Bilingual in English and in Arabic, Chinese, Farsi, Korean, Spanish, or Vietnamese preferred.
  

Knowledge & Abilities:

• Develop rapport and establish and maintain effective working relationships with CalOptima Health's 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.
  

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”