Grievance and Appeals

The Judge Group is seeking a Grievance Resolution Specialist for a fantastic client of ours in Orange, CA! This is a great way to get your foot in the door with one of Orange Countys largest HealthPlans!Below you can find some information about this opportunity! Qualified candidates are encouraged to apply!Job **We are seeking a highly motivated and experienced Grievance Resolution Specialist (Provider Resolution) to join our team. The Grievance Resolution Specialist will coordinate the Grievance and Appeal resolution process, responding to verbal and written Grievances and Appeals from members and providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, pharmacy, and vision decisions.Key *Coordinate the Grievance and Appeal resolution process.Respond to verbal and written Grievances and Appeals from members and providers.Address issues related to member eligibility and benefits, contract administration, claims processing, utilization management decisions, pharmacy, and vision decisions.Maintain frequent external contact with members and families, health care providers, health networks, third party administrators, and regulators.Collaborate with internal departments such as Customer Service, Provider Relations, Pharmacy, and Medical Management to identify factors necessary for the optimal resolution of Grievances and Appeals.Minimum *High school diploma or equivalent PLUS 1 year of experience with Provider Dispute Resolution (PDR) in Medicare and Medi-Cal in professional, institutional, outpatient, ancillary, coordination of benefits, and government cases required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.1 year of experience with Medicare or Medi-Cal provider appeals and denials process required.1 year of experience in any of the following ** Grievances and Appeals, Claims Administration, Regulatory Compliance, Customer Service, or related field required.Preferred *****Associate degree in business, health care administration, or related field.Experience in health care practice standards, for both government and commercial plans.Bilingual in English and in one of the defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).

Created: 2025-05-22