Program Assistant, Grievance & Appeals

CalOptima is a mission-driven community-based organization that serves member health with excellence and dignity. The Program Assistant will assist with specialized services relevant to the Grievance and Appeals Resolution Services department, monitoring member and provider inquiries and processing appeals and grievances in a timely manner.

Responsibilities

• 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
• Serves as the point of contact within or outside CalOptima Health 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 inquiry requests from the Department of Managed Health Care (DMHC), Medicare Complaint Tracking Module (CTM) from the Centers for Medicare Medicaid Services (CMS), Medicare Quality Improvement Organization (QIO) and the State Hearing Office from Department of Social Services (DSS)
• Responds to DMHC requests for information in a timely manner
• Sets up complaint case files, enters cases in the GARS system with accurate classification and category types and assigns them to appropriate staff
• Works with internal and external departments and providers in gathering supporting information relevant to the case
• Generates acknowledgment letters for all lines of business per department and regulatory standards
• Assists in the development of departmental forms and intake processes
• Coordinates administrative support for state hearings, serves as a contact with DSS for incoming cases, enters cases in the GARS system, creates electronic files and routes the scanned documents to designated staff and fax required state hearing documentation to the local hearing office as necessary
• Completes other projects and duties as assigned

Skills

• High school diploma or equivalent PLUS 1 year of experience in appeal and grievance guidelines, 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 may also be qualifying
• 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
• Manage multiple projects and identify opportunities for internal and external collaboration
• Motivate and lead multi-program teams and external committees/coalitions
• 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
• Ability to visually read information from computer screens, forms and other printed materials and information
• Ability to speak (enunciate) clearly in conversation and general communication
• Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions
• Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting
• Lifting and moving objects, patients and/or equipment 10 to 25 pounds
• Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese)

Benefits

• A comprehensive benefits package
• CalPERS pension program and additional retirement packages.
• A generous PTO program
• A quality work life balance
• Various wellness programs
• Tuition Reimbursement
• Professional development opportunities
• Career development opportunities
• Flexible scheduling

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