Grievance Resolution Specialist Members - TEMP

At Sunshine Enterprise USA were not just a company; were a community of dedicated professionals committed to excellence and innovation. As a leading force in the business landscape we take pride in bringing together great people and great organizations by fostering a work environment that values creativity diversity and growth. If youre ready to embark on a rewarding career journey with a company that prioritizes its employees explore our current job opportunities below.

Job Summary

The Grievance Resolution Specialist coordinates the Grievance and Appeal resolution process responds to verbal and written Grievances and Appeals from members and/or providers relating to member eligibility and benefits contract administration claims processing utilization management decisions and pharmacy and vision decisions. The incumbent has frequent external contact with members and families healthcare providers health networks thirdparty administrators and regulators. The incumbent collaborates with internal departments such as Customer Service Provider Operations Pharmacy and Medical Management to identify factors necessary for the optimal resolution of Grievances and Appeals.

Position Responsibilities

Participates in a missiondriven culture of highquality 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 longterm goals/priorities for the department.

Maintains adequate information in CalOptima Health 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 but not limited to member or provider concerns supporting information related to initial decisionmaking new information supporting the grievance or appeal or supplemental information required to evaluate grievances and appeals within regulatory requirements.

Coordinates and/or participates in case discussion with operational experts to result in a final case disposition as needed.

Evaluates case details proposes recommendations or makes decisions as applicable; ensures organization 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 Quality Improvement department as applicable and facilitates responses to members according to CalOptima Health policy.

Assists with Health Networks compliance process.

Identifies trends and root cause of issues; proposes solutions or escalates ongoing issues to management.

Meets performance measurement goals for Grievance and Appeals Resolution Services.

Completes other projects and duties as assigned.

Possesses the Ability To:

Exercise discretion in processing confidential information.

Identify critical issues and make recommendations or decisions by using critical thinking skills.

Document and present case research findings and formulate resolution letters.

Communicate clearly and concisely both orally and in writing.

Establish and maintain effective working relationships with the leadership and staff.

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.

Experience & Education

High School diploma or equivalent required.
1 year of experience in any of the following areas: Grievances and Appeals Claims Regulatory Compliance Customer Service or related fields 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

Associate degree in Business Health Care Administration or related field.

Experience in healthcare practice standards for both government and commercial plans.

Bilingual in English and in one of CalOptima Healths defined threshold languages (Arabic Farsi Chinese Korean Spanish Vietnamese).

Knowledge of:

Associate degree in Business Health Care Administration or related field.

Experience in healthcare practice standards for both government and commercial plans.

Bilingual in English and in one of CalOptima Healths defined threshold languages (Arabic Farsi Chinese Korean Spanish Vietnamese).

At Sunshine Enterprise USA LLC we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits:

Competitive pay & weekly paychecks

Health dental vision and life insurance

401(k) savings plan

Awards and recognition programs

Benefit eligibility is dependent on employment status.

Sunshine Enterprise USA is an Equal Opportunity Employer Minorities Females Veterans and Disabled Persons