Grievance Resolution Specialist

Johnson Service Group (JSG) is seeking a Grievance Resolution Specialist for a health insurance group in Orange, CA. This is an on-site contract (Temporary position up to 6 months) Pay range $25.00- $36.00 DOE Work hours- Monday- Friday 8 : 00am- 5 : 00 pm. Duties & Responsibilities : 95% - Program Support Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals / priorities for the department. Maintains adequate information in company'sHealth’s systems; ensures data collection, summarization, integration and reporting which includes case creation and management and events / activity tracking. 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 and 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. Contacts appropriate parties to request and obtain missing information and supporting documentation or provides education. Reads and interprets provider contracts, Division of Financial Responsibility (DOFR), policies, procedures and instructions. Responds to routine provider inquiries via phone, assisting with provider appeals resolution inquiries. Assists with the health networks’ compliance process. Identifies trends and root causes of issues, proposes solutions or escalates ongoing issues to management. Meets performance measurement goals for Grievance and Appeals Resolution Services. 5% - Completes other projects and duties as assigned. Minimum Qualifications : High school diploma or equivalent PLUS 1 year of experience with Provider Dispute Resolution (PDR) in Medicare and Medi-Cal in professional, institutional, outpatient, ancillary, coordination of benefits and government cases required; 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. 1 year of experience with Medicare or Medi-Cal provider appeals and denials process required. 1 year of experience in any of the following areas : Grievances and Appeals, Claims Administration, Regulatory Compliance, Customer Service or related field required. Preferred Qualifications : Associate degree in business, health care administration or related field. Experience in health care practice standards, for both government and commercial plans. Bilingual in English and in one of the company's Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese). JSG offers medical, dental, vision, life insurance options, short-term disability, 401(k), weekly pay, and more. Johnson Service Group (JSG) is an Equal Opportunity Employer. JSG provides equal employment opportunities to all applicants and employees without regard to race, color, religion, sex, age, sexual orientation, gender identity, national origin, disability, marital status, protected veteran status, or any other characteristic protected by law. #D800

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