About Clever Care Health Plan

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.

Job Summary

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.

Functions and Job Responsibilities

  • Maintains and coordinates staff activities to achieve departmental and corporate goals to improve service to customers/providers and assures regulatory compliance.
  • Research grievances and appeals and logs and tracks the information as it moves through the clinical process or is tasked through internal contacts.
  • Use sound, fact-based decision-making skills to render a decision for non-clinical complaints
  • Contact members to collect information and communicate disposition of the case and document all interactions.
  • Create job aids and assist to maintain desk level procedures.
  • Implements education strategies targeted at member orientation, retention, wellness, HEDIS measures, and to reduce member grievances and appeals.
  • Addresses customer, provider, and other department’s needs, and concerns related to the Grievance, Appeals & Customer Solution Center department.
  • Prepares appeal summaries, correspondence; and documents information for tracking/trending data; assists in the preparation of narratives, graphs, flowcharts, etc. for presentations and audits.
  • Perform focused quality sampling audits and report findings to management.
  • Maintain familiarity and compliance with federal, state and local regulations as well as other regulatory requirements (e.g. NCQA standards) relative to appeal and grievance operations.
  • Assist with HEDIS production functions including data entry, calls to provider’s offices, and claims research.
  • Identify and report trends seen in grievances, appeals, and medical records to management.
  • Validates integrity and accuracy of data outputs for Grievance, Appeal and Customer Solution Center reporting.
  • Assist the Member Services department with overflow calls during periods of high volume and outbound campaigns as necessary.
  • Prepare reports for presentation at various committees (e.g. Medical Services Committee, Executive Board Meetings, Compliance Committee, etc.,) as requested.
  • Assist members in a caring and knowledgeable manner, representing the organization as a skilled health professional.

Education and Experience

  • 2+ years previous experience working in a MAPD Grievance and Appeals role

Knowledge, Skills, and Abilities

  • Ability to work in a fast-paced environment with changing priorities
  • Knowledge of healthcare industry coding theory, rules, and standards (CPT, HCPCS, Revenue, ICD9, DRG, etc.).
  • Knowledge of CMS regulations related to Appeals & Grievances and Complaints Tracking Module (CTM)
  • Ability to ensure organizational compliance with all required rules, policies, and procedures
  • Requires strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
  • Results oriented
  • Ability to perform analysis and apply sound reasoning in problem solving
  • Problem solver
  • Intermediate knowledge of Microsoft Word, Excel, and Microsoft PowerPoint
  • Bilingual in Korean, Vietnamese, or Mandarin preferred

Physical & Working Environment

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.

Apply for the Grievances & Appeals Resolution Specialist position at Clever Care Health Plan