Grievance & Appeals Assistant

  • Location
    Camarillo, California
  • Job type
    Direct Hire
  • Salary
    $ 15 - $ 20 / Hour
  • Category
    Medical & Science - Patient Care / Management

ESSENTIAL FUNCTIONS
To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each
essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to
perform the essential functions.
Essential Functions Statement(s)
� Develop and maintain adequate information systems to assure timely and effective data collection, summarization, integration,
and reporting which includes, but is not limited to, case creation and management and events/activity tracking.
� Ensure compliance with grievance policies and assist with timely case resolution.
� Process intake of appeals and grievances into the department's tracking database and/or systems.
� Monitor incoming correspondence/faxes and route to appropriate staff in a timely manner in accordance with established
procedures.
� Monitor incoming correspondence/faxes and route to appropriate staff in a timely manner in accordance with established
procedures.
� Route incoming grievances and appeals to the G&A Specialists for further action in a timely manner, compliant with timelines
established by regulatory agencies.
� Identifies and initiates appropriate appeals into the expedited appeals process.
� Route misdirected non-G&A issues to correct staff for timely and appropriate action.
� Route misdirected non-G&A issues to correct staff for timely and appropriate action.
� Assist in gathering comprehensive documentation, as needed, from varied internal and external sources relevant to issue
raised in grievance/appeal.
� Assist team in documenting/updating cases in tracking database and/or systems and maintain accurate grievance/appeal
records.
� Ensure all relevant material is complete for State Fair Hearing.
� Maintain filing system and ensure all case files are stored timely and accurately in the appropriate applications.
� Assists departmental management in tracking and trending appeals and grievances.
� Maintain office supply inventory for the department.
� Assist with and participate in meetings as assigned.
� Performs other duties as assigned.

POSITION QUALIFICATIONS
� Technical Aptitude - Ability to comprehend complex technical topics and specialized information.
� Deductive Reasoning - Ability to apply principles of logical or scientific thinking to a wide range of intellectual and practical
problems.
� Customer Oriented - Ability to take care of the customers� needs while following company procedures.
� Organized - Possessing the trait of being organized or following a systematic method of performing a task.
� Time Management - Ability to utilize the available time to organize and complete work within given deadlines.
� Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job
type.
SKILLS & ABILITIES
Education: High School Graduate or General Education Degree (GED): Required
Bachelor's Degree (four year college or technical school) Preferred, Field of Study:
Business, Healthcare, Managed Care, Claims
Experience: 1 plus years of experience in a managed care environment, preferably with grievance
and appeals or claims processing background.
Medi-Cal/Medicaid managed care experience strongly desired.
Computer Skills: Advanced computer skills included in the MS Office products (Word, Excel, PowerPoint, and Access).
Certifications &
Licenses:
A valid California Driver's License.
Other Requirements: Knowledge Of:
Grievance and appeals rules and processes.
Principles and practices of managed care, Medi-Cal eligibility and benefits.
Medical billing/coding (CPT, HCPCS, ICD-9, ICD-10) and medical terminology.
Advanced computer skills that include MS Office products.
Ability to:
Assist in the creation of policies, procedures and workflows.
Communicate effectively in writing, orally, and with others to assimilate, understand, and
convey information, in a manner consistent with job functions.
Organize own work, set priorities, meet critical deadlines, and follow-up on assignments with
a minimum of direction.
Maintain confidentiality regarding sensitive information.
Comprehend and interpret policies and regulations.

ESSENTIAL FUNCTIONS
To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each
essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to
perform the essential functions.
Essential Functions Statement(s)
� Develop and maintain adequate information systems to assure timely and effective data collection, summarization, integration,
and reporting which includes, but is not limited to, case creation and management and events/activity tracking.
� Ensure compliance with grievance policies and assist with timely case resolution.
� Process intake of appeals and grievances into the department's tracking database and/or systems.
� Monitor incoming correspondence/faxes and route to appropriate staff in a timely manner in accordance with established
procedures.
� Monitor incoming correspondence/faxes and route to appropriate staff in a timely manner in accordance with established
procedures.
� Route incoming grievances and appeals to the G&A Specialists for further action in a timely manner, compliant with timelines
established by regulatory agencies.
� Identifies and initiates appropriate appeals into the expedited appeals process.
� Route misdirected non-G&A issues to correct staff for timely and appropriate action.
� Route misdirected non-G&A issues to correct staff for timely and appropriate action.
� Assist in gathering comprehensive documentation, as needed, from varied internal and external sources relevant to issue
raised in grievance/appeal.
� Assist team in documenting/updating cases in tracking database and/or systems and maintain accurate grievance/appeal
records.
� Ensure all relevant material is complete for State Fair Hearing.
� Maintain filing system and ensure all case files are stored timely and accurately in the appropriate applications.
� Assists departmental management in tracking and trending appeals and grievances.
� Maintain office supply inventory for the department.
� Assist with and participate in meetings as assigned.
� Performs other duties as assigned.

POSITION QUALIFICATIONS
� Technical Aptitude - Ability to comprehend complex technical topics and specialized information.
� Deductive Reasoning - Ability to apply principles of logical or scientific thinking to a wide range of intellectual and practical
problems.
� Customer Oriented - Ability to take care of the customers� needs while following company procedures.
� Organized - Possessing the trait of being organized or following a systematic method of performing a task.
� Time Management - Ability to utilize the available time to organize and complete work within given deadlines.
� Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job
type.
SKILLS & ABILITIES
Education: High School Graduate or General Education Degree (GED): Required
Bachelor's Degree (four year college or technical school) Preferred, Field of Study:
Business, Healthcare, Managed Care, Claims
Experience: 1 plus years of experience in a managed care environment, preferably with grievance
and appeals or claims processing background.
Medi-Cal/Medicaid managed care experience strongly desired.
Computer Skills: Advanced computer skills included in the MS Office products (Word, Excel, PowerPoint, and Access).
Certifications &
Licenses:
A valid California Driver's License.
Other Requirements: Knowledge Of:
Grievance and appeals rules and processes.
Principles and practices of managed care, Medi-Cal eligibility and benefits.
Medical billing/coding (CPT, HCPCS, ICD-9, ICD-10) and medical terminology.
Advanced computer skills that include MS Office products.
Ability to:
Assist in the creation of policies, procedures and workflows.
Communicate effectively in writing, orally, and with others to assimilate, understand, and
convey information, in a manner consistent with job functions.
Organize own work, set priorities, meet critical deadlines, and follow-up on assignments with
a minimum of direction.
Maintain confidentiality regarding sensitive information.
Comprehend and interpret policies and regulations.

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Reference number US_EN_1_025132_11804362