Represents Partnership in the Grievance & Appeals Resolution process. Responsible for reviewing,investigating, and resolving assigned member grievance and appeal cases ranging from low tohigh complexity. Works to transform member dissatisfaction into member satisfaction. Overseesthe investigative process ensuring casework complies with DHCS guidelines, NCQA standards,and Partnership best practices. Works independently, provides leadership on each investigation,prioritizes case deliverables, remains customer-focused, and stays current on changes in thehealthcare system that may trigger member dissatisfaction.
Responsibilities- Independently determines best resolution on assigned cases, incorporating clinical guidancefrom Partnership Medical Directors and Grievance & Appeal Nurse Specialists.
- Investigates member-disputes of denied benefits/services, collects new evidence, reassessesfor coverage, executes final decisions, and communicates it to all stakeholders.
- Investigates member-reported concerns about dissatisfactory experiences while seeking care.Identifies facts, surveys the health care system, corrects root causes, and communicatesoutcomes to all stakeholders.
- Communicates with members throughout the investigation, offers customer-focusedsolutions, and practices exemplary customer service to all stakeholders. Frequent contactwith internal departments, providers, third party administrators, and/or regulators.
- Manages assigned cases so they are completed within DHCS timeframes, according to G&ADesktop procedures, and/or as directed by management.
- Documents all casework activity thoroughly, accurately, timely, and ethically.
- Writes DHCS and NCQA compliant letters to members and providers.
- Provides leadership to the grievance support team to complete sub-components of the investigation process.
- Effective communicator in all modes of communication (e.g., written, verbal).
- Knows all Partnership Medi-Cal benefits or has the ability to master understanding of all benefits.Maintains knowledge of Partnership Medi-Cal Handbook, Partnership Policy & Procedures, and DHCSguidelines affecting benefits.
- Identifies systematic or recurring issues that create barriers to high quality healthcare andreports them to leadership.
- May serve as backup to absent Grievance & Appeals Case Analyst(s).
- Attends meetings as needed including but not limited to Case Conferences, Case ForumMeetings, Department Meetings, and Division Meetings.
- Other duties as assigned.
Education and Experience
Bachelor’s degree or four (4) years of related work experience, preferably inGrievances & Appeals, health care customer service, case management orhealth plan operations.
Special Skills, Licenses and Certifications
Ability to solve problems, be a critical thinker and detail oriented. Familiarwith managed care concepts, operations, policies and procedures, includingbut not limited to knowledge of grievance and appeal regulations. Strongknowledge of Microsoft Word, Excel, and Outlook. Bilingual skills inSpanish, Tagalog, or Russian preferred, but not required.
Performance Based Competencies
Excellent oral and written communication skills. Ability to exercise discretionand independent judgment. Must be able to handle multiple tasks and meetdeadlines. Strong organizational skills with ability to prioritize work. Must beable to work in a fast-paced environment, work well under pressure, andmaintain professional composure when interacting with all stakeholders,including members.
Work Environment And Physical Demands
Daily use of telephone and computer. More than 70% of work time is spent infront of a computer monitor. Standard cubical workstation. When required,ability to move carry or lift objects weighing up to 25 lbs.
All HealthPlan employees are expected to:
- Provide the highest possible level of service to clients;
- Promote teamwork and cooperative effort among employees;
- Maintain safe practices; and
- Abide by the HealthPlan’s policies and procedures, as they may from time to time be
HIRING RANGE:
$74,897.69 - $93,622.12
IMPORTANT DISCLAIMER NOTICE
The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.
Skills Required
- Bachelor's degree or four years of related work experience
- Experience in grievances and appeals, healthcare customer service, case management, or health plan operations
- Ability to solve problems, think critically, and demonstrate attention to detail
- Familiarity with managed care concepts, operations, policies, procedures, and grievance and appeal regulations
- Strong knowledge of Microsoft Word, Excel, and Outlook
- Excellent oral and written communication skills
- Ability to exercise discretion and independent judgment
- Ability to handle multiple tasks, meet deadlines, prioritize work, and perform under pressure
- Bilingual skills in Spanish, Tagalog, or Russian
- Ability to move, carry, or lift objects weighing up to 25 pounds when required
What We Do
Partnership HealthPlan of California is a nonprofit, community-based health care organization and managed-care plan. It contracts with the state to administer Medi-Cal benefits through local care providers, helping recipients access high-quality, comprehensive, and cost-effective care. Its mission is to help its members and the communities it serves be healthy, while coordinating health services across Northern California and supporting local providers.
