Grievance and Appeals Case Analyst
Company: Partnership HealthPlan of California
Location: Fairfield
Posted on: May 14, 2022
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Job Description:
Overview
Represents PHC 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 PHC 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
Qualifications
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. Valid Californiadriver's license and
proof of current automobile insurance compliant withPHC policy are
required to operate a vehicle and travel for companybusiness.
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.
Additional Comments:
This is a full-time remote position.
All HealthPlan employees are expected to:
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.
Keywords: Partnership HealthPlan of California, Fairfield , Grievance and Appeals Case Analyst, Professions , Fairfield, California
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