Grievance Specialist

We have an opportunity as a Grievance Specialist on the Grievance Team. *The focus for this role will be with behavioral health concerns.

Grievance work involves complex coordination, investigation and specific resolution(s) within regulatory timeframes.  Areas of Grievance work include:

• Appeals: A member complaint involving an adverse benefit determination by an Alliance Utilization Management (UM) decision.
• Member Grievances (Complaints): An oral or written statement submitted by a member or a member's authorized representative expressing dissatisfaction with any aspect of the Alliance's health care plan.
• Expedited Appeals/ Grievances: A complaint or Appeal involving an imminent and serious threat to the health of the member, as determined by an Alliance Medical Director that includes, but is not limited to, severe pain, potential loss of life, limb or major bodily function.
• State Fair Hearings: The process whereby a member enrolled in Medi-Cal requests the Department of Social Services (DSS) and its Administrative Law Division to resolve Plan decisions that deny, modify or delay health care services or affect Medi-Cal benefits.
• Inquiries: A question or request for information or assistance by a member that does not reflect the member's dissatisfaction with any aspect of the Alliance's health care plan.
• Complex Member Billing Issues or Member Reimbursements: When an Alliance member receives a bill from a medical provider for covered services or paid out of pocket for covered Medi-Cal services.

WHAT YOU'LL BE RESPONSIBLE FOR

• Supporting the administration and resolution of medium complexity cases in support of the Alliance Grievance function
• Assisting the Grievance and Quality Leadership with daily operations and serving as a backup for Grievance and Subject Matter Expert (SME) Training
• Participating in departmental and cross departmental trainings, workgroups, and operational improvement activities

About the Team:

We support the Alliance grievance function and follow all regulatory requirements. Our small yet mighty team works across the organization seeking to solve problems for our members while staying up to date on any policy changes. We manage case work with strict timeframes, communicate regularly with members, providers and within our team.

THE IDEAL CANDIDATE 

• Has a behavioral health background and awareness of possible patient issues while receiving behavioral health services
• Is capable of following business procedures while also comfortable working in grey or ambiguous situations 
• Has demonstrated experience and comfort with having difficult conversations
• Is comfortable working in evolving environments and understands when discretion is needed
• Has the ability to communicate issues accurately and timely
• Is detail oriented, highly organized and thrives in a fast-paced environment
• Has a passion for presenting new ideas and collaborating with others  
• Has experience with managing cases and contributing to process improvement
• Easily wears multiple hats to get the work done, and enjoys being flexible along the way

WHAT YOU'LL NEED TO BE SUCCESSFUL

To read the full position description, and list of requirements click here. 

• Knowledge of:
• Principles and practices of managed healthcare, healthcare coverage and benefit structures, principles of coordination of benefits and medical billing
• Title 22 and Title 28 utilization management and grievance regulations
• Diverse needs of the Medi-Cal population
• Principles and practices of customer service
• Ability to:
  • Understand and communicate the complex operations and processes of the Alliance, including those related to Utilization Management, Care Management and Member Services departments
  • Identify issues, conduct research and investigations, gather and analyze information, reach logical and sound conclusions, and offer recommendations and potential consequences
  • Interpret legal, regulatory and contractual language, policies, procedures and guidelines, and legislative and regulatory directives
  • Prepare reports, correspondence and other program documents
• Education and Experience:
  • Bachelor’s degree in Health, Social Science, or a related field and a minimum of three years of experience in a managed health care setting, health plan or provider office performing work related to processing provider claims, including a minimum of one year of experience administering provider disputes or member appeals and grievances (a Master’s degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying
    
    

OTHER INFORMATION

• We are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft Teams.
• While some staff may work full-time telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected.
• In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process.

The full compensation range for this position is listed by location below. 

The actual compensation for this role will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferrable experience related to the position, education or training), as well as other factors (internal equity, market factors, and geographic location).

OTHER INFORMATION

• We are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft Teams.
• While some staff may work full telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected.
• In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process.

The full compensation range for this position is listed by location below. 

The actual compensation for this role will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferrable experience related to the position, education or training), as well as other factors (internal equity, market factors, and geographic location).