State Hearing Representative

The State Hearing Representative has overall responsibility for assigned State Hearings, court cases for Partnership members contesting the outcome of Appeals and/or Grievances decisions. This position will represent Partnership HealthPlan of California at Department of Social Services (CDSS) court hearings. Responsible for establishing course of action to resolve conflict with Partnership members, case research, preparation of legal documents, coordination of internal resources, submission of cases to CDSS, conducting case hearings, and final outcome. Negotiates case withdrawals with Partnership members. May handle ADA 1557 discrimination cases. May handle high-profile and staff-complaint grievance and/or appeal cases. Provides expert guidance to Grievance & Appeal Coordinators on complex casework.Represents Partnership HealthPlan of California in State Hearings. Serves as an expert in handling and resolving the spectrum of member issues reported in all grievances and appeals casesWorks independently and exercises excellent judgement in representing Partnership HealthPlan at State HearingsResponsible for completion of entire lifecycle of assigned State Hearing cases: Self-assigns case on CDSS Appeals Case Management System (ACMS), manages all case-specific activities in Everest, conducts case research, coordinates with Medical Directors, collaborates with legal, prepares legal documents, conducts hearing, and executes court decisions.Demonstrates empathy and works calmly with dissatisfied membersConsistently practices the handling of PHI/PII data with sensitively and strict confidentiality.Negotiates with members to withdraw state hearings by rectifying problemsCollaborates with the Regulatory and Affairs Department to ensure Partnership HealthPlan of California’s best interest is represented throughout state hearing processCommunicates case hearing decisions to managementServes as an expert on State Hearing processes, guidelines, laws, and best practices. Creates desktops, policy & procedures to ensure compliances with all regulatory and industry requirements. Will train staff on State Hearings as neededBased on lessons learned from State Hearing trends, provides recommendations to management that reduces State Hearings through improved best practicesHandles Americans with Disabilities Act (ADA) 1557 discrimination grievancesMay handle very high-profile grievance and/or appeal casesMay handle sensitive complaints against Partnership Health Plan of California staffMay assist with the development of internal audit criteria and practicesMay attend and represent Grievance & Appeals in internal committeesMay serve as a back-up to audit Grievance & Appeals staffMay serve as a back-up to Grievance & Appeals SupervisorMay conduct training to onboarding new Grievance & Appeals staffAttends and may facilitate departmental meetingsCompletes all State Hearing and casework according to DHCS, NCQA, and Grievance & Appeals mandated timeframes and best practicesMust be available after normal work hours and/or weekends to ensure Partnership HealthPlan of California meets all obligations accurately and timelySECONDARY DUTIES AND RESPONSIBILITIESConducts other projects, initiatives, and/or duties as assignedMINIMUM HIRING CRITERIAEducation and ExperienceBachelor's degree in related field; minimum five (3) years’experience ina managed care health insurance environment; (3) years’ experienceprocessing Grievance and Appeals cases; experience with CDSS StateHearing cases a plus; paralegal experience in a health care environmentis a plus; or equivalent combination of education and experience.Special Skills, Licenses and CertificationsThorough working knowledge of managed care concepts, policies, andprocedures, including but not limited to, knowledge of grievance andappeal regulations (e.g. Title 10 CCR, Title 22 CCR, Title 28 CCR, Healthand Safety Code 1340 et seq., 42 CFR 422 and 423, Medicare ManagedCare and PrescriptionDrug Manuals, etc.). Ability tounderstand,interpret, andprepare documentation used in legal cases. Paralegaltraining desired . Working knowledgeof businesssoftwareapplications.AdvanceexperiencewithWindowsandrelatedapplications. Familiaritywith database applications. Knowledge ofmedical terminology and ability tounderstand and interpretmedicaldecisions. Proficient use of computerkeyboard to access data. Bilingualskills in Spanish, Tagalog, or Russianmay be required. Valid Californiadriver’s license or the ability to securealternative transportation may berequired.Performance Based CompetenciesStrong leadership skills are required. Must be comfortable holding people accountable for quality of work and have the ability to determine if casework did not meet department standards. Ability to work independently, with minimal supervision, and complete tasks within established strict time frames. Ability to use sound/professional judgment and to handle complex issues independently but with the knowledge and ability to escalate and ask for assistance when needed. Ability to assess and resolve customer complaints, problems, and issues in an effective manner. Demonstration of conflict resolution and mediation skills. Ability to interview and investigate emotional situations with a level of sensitivity and understanding. Consistently demonstrate the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to internal staff, members, and providers. Professional phone etiquette and customer service orientation necessary. Ability to learn quickly and acquire in-depth knowledge of software used at Partnership. Excellent written and verbal communication skills with the ability to write comprehensive statements, summaries, and prepare reports using proper grammar and sentence structure. Ability to listen effectively and appropriately respond to difficult and/or urgent situations. Attention to detail and excellent organizational skills are required. Ability to multitask and manage time in order to perform well on long term projects while being flexible enough to assimilate short-term projects on an ongoing basis. Excellent and very thorough follow through skills. Excellent analytical and interpersonal skills and the ability to problem solve creatively, objectively, and rapidly. Ability to prioritize issues, use good judgment skills, and handle sensitive issues with confidentiality, tact, and diplomacy. Decision-making and critical thinking skills are required.Display great initiative and ability to sense urgency. Ability to cope and deal with a high volume of tasks and demanding situations. Adaptable to a constantly changing environment and ability to work independently and with a team is a must.Work Environment And Physical DemandsAbility to use a computer keyboard. More than 80% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects, weighing up to 25 lbs.All HealthPlan employees are expected to:Provide the highest possible level of service to clients;Promote teamwork and cooperative effort among employees;Maintain safe practices; andAbide by the HealthPlan’s policies and procedures, as they may from time to time be updated.HIRING RANGE:$93,690.86 - $117,113.58IMPORTANT DISCLAIMER NOTICEThe job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

Created: 2025-11-15