Remote- und Homeoffice Jobs in merced-county-california ∙ Seite 1

ABOUT THIS TEMP POSITION

We have opportunities to join the Alliance as a Temporary Grievance Coordinator in the Member Services Department. These positions will require in office presence in either our Merced or Scotts Valley office (hybrid).

This is a temporary position and the length of assignment is estimated to go for 3-6 months. The length of the assignment is always dependent on business need and dates may change. While the assignment would be at the Alliance, if selected, you would be an employee of a temporary employment agency that we would connect you with.

WHAT YOU'LL BE RESPONSIBLE FOR

Reporting to the Grievance Supervisor, this position:

• Assists in the administration and resolution of low complexity cases in support of the Alliance Grievance function
• Performs administrative duties to track, organize, monitor, and follow up on case work
• Participates in departmental and cross-departmental trainings, workgroups, and operational improvement activities
• Performs other duties as assigned

ABOUT THE TEAM

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 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 billings
• Title 22 and Title 28 utilization management and grievance regulations
• The diverse needs of the Medi-Cal population
• Customer services principles and practices 
• Ability to:
  • Understand and communicate the complex operations and processes of the Alliance, particularly the Utilization Management, Care Management, and Member Services departments
  • Use the Alliance's internal tracking systems
  • Draft professional correspondence
  • Learn and utilize computer systems and verbally communicate the program mission, vision, and roles
• Education and Experience:
  • Associate's degree in health, social services or a related field and one year of experience in a managed health care setting, health plan, or provider office interacting with members, patients, or providers and receiving complaints, preferably related to healthcare administration or public assistance; 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 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.