Grievance & Appeals Resolution Specialist

Orange, CA | Temp-to-Hire

Job ID: [SA] GARS Industry: Healthcare Pay Rate: $18.00

Coordinate the overall process of complaint resolution, responding to all verbal and written complaints from members and/or providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, pharmacy and vision decisions. Has frequent external contact with members and families, health care providers, organizations and regulators.  Frequently interacts with and plays a key role in collaborating with internal contacts in Customer Service, Provider Operations, Pharmacy, TPA Vision Administrator, Medical Management and other resources to identify factors necessary for the optimal resolution of complaints. 

 Position Responsibilities

    • Develop and maintain adequate information systems to assure timely and effective data collection, summarization, integration, and reporting which includes, but not limited to, case creation and management and events/activity tracking.
    • Ensure compliance to Grievance Policy and timely case resolution.
    • Gather pertinent information regarding complaint(s), including, but not limited to, member or provider concern, supporting information related to initial decision, new information supporting complaint, supplemental information required to evaluate complaint and regulatory requirements.
    • Coordinate and/or participate, as needed, in case discussion with operational experts to result in a final case disposition.
    • Evaluate case details and propose recommendation/decision.
    • Ensure organization decision is implemented.
    • Meet performance measurement goals for Grievance and Appeals Resolution Services.
    • Assure adequate and timely communication within the Grievance and Appeals Resolution Services and with other departments and external customers.
    • Initiate referrals to Quality Improvement Department as indicated and facilitate response to members according to policy.


  • 1-2 years of experience in claims processing or appeals and grievances highly desirable.
  • Customer service experience preferred.
  • Experience in Healthcare practice standards, for both government and commercial plans.
  • An Associate’s degree or higher in Humanities, Social Science, Health Care or Business is preferred.
  • Bilingual is preferred.

Work Environment / Disclaimer

  • Work Environment: Moderate noise levels due to call center operations. Frequent interruptions are common. Office temperatures are controlled and comfortable.

 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 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



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We will consider for employment all qualified Applicants, including those with Criminal Histories, in a manner consistent with the requirements of applicable state and local laws, including the California Fair Employment and Housing Act (FEHA).

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