Adjudication, Analysis Skills, Billing, Communication Skills, County Ordinances, Data Collection, Detail Oriented, Documentation, Health Insurance, Health Maintenance Organization (HMO), Healthcare, Healthcare Providers, High School Diploma, Maintain Compliance, Microsoft Excel, Microsoft Office, Microsoft Word, Multitasking, Problem Solving Skills, Quality of Care, Regulatory Compliance, Regulatory Requirements, State Laws and Regulations, Time Management, Writing Skills
Appeals & Grievances Specialist I
Location: Sacramento, CA (Hybrid)
Employment Type: Full-Time
Pay: $22.00-$25.00/hour
Position Summary
Our client is seeking an Appeals & Grievances Specialist to investigate, coordinate, and resolve member appeals and grievances while ensuring compliance with regulatory requirements and established timelines. This role requires strong analytical skills, attention to detail, and the ability to manage multiple priorities in a fast-paced healthcare environment.
Key Responsibilities
- Investigate and resolve member appeals, complaints, and grievances.
- Research issues related to claims, benefits, authorizations, billing, enrollment, and quality of care.
- Gather information from members, providers, medical groups, and internal departments.
- Ensure accurate documentation and timely case resolution.
- Draft member correspondence, including acknowledgment and resolution letters.
- Identify and escalate urgent, compliance, privacy, or quality-of-care concerns.
Qualifications
- High school diploma or equivalent.
- 2+ years of experience in health insurance, appeals and grievances, or claims.
- Strong analytical, problem-solving, and communication skills.
- Proficiency with Microsoft Office, including Word and Excel.
- Experience with HMO plans, claims adjudication, referrals, authorizations, or regulatory compliance is strongly preferred.
All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance.
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Ultimate Staffing Services