Position Type: Full Time
Location: Hybrid; Arcadia, CA
Reports To: Grievance, Appeals, & Customer Solution Center Manager
Clever Care Health Plan is a newly founded Medicare Advantage health plan serving Medicare beneficiaries in Southern California. Our employees are passionate in providing best services to our members and healthcare providers. Our three office locations are in Arcadia (Los Angeles County), Huntington Beach (Orange County) and New York City.
Under the direction of the Grievances & Appeals Customer Solution Manager and the Grievances & Appeals Customer Solution Supervisor, the Grievance & Appeals Resolution Specialist will assist with the intake and resolution process for member grievances, appeals and provider disputes, ensuring CMS compliance and NCQA standards and with the State and other mandated guidelines. Grievance & Appeals Resolution Specialist works within thorough, prescribed guidelines and procedures; uses independent judgment requiring analysis of variable factors to solve intermediate problems; collaborates with management and top professionals/specialists in selection of methods, techniques, and analytical approach. Development of policies, procedures, processes, and front-line staff practices to ensure contract compliance. The Grievance & Appeals Resolution Specialist may also assist the Member Services department with overflow calls and outbound campaigns as deemed necessary.
Typical Physical Demands.
Position requires a great amount of sitting and standing. Some lifting, stooping, bending, or reaching is required. May require lifting up to 15‐30 pounds. Requires manual dexterity sufficient to operate a computer, calculator and telephone. Requires normal range of hearing and vision. Requires the ability to type and file.
Typical Working Conditions.
Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. Work may be stressful at times. May occasionally work some irregular hours.