Grievance and Appeals Case Analyst
Company: Partnership HealthPlan of California
Posted on: January 12, 2022
Overview:Represents PHC in the Grievance & Appeals Resolution
process. Responsible for reviewing,
investigating, and resolving assigned member grievance and appeal
cases ranging from low to
high complexity. Works to transform member dissatisfaction into
member satisfaction. Oversees
the investigative process ensuring casework complies with DHCS
guidelines, NCQA standards,
and PHC best practices. Works independently, provides leadership on
prioritizes case deliverables, remains customer-focused, and stays
current on changes in the
healthcare system that may trigger member
- Independently determines best resolution on assigned cases,
incorporating clinical guidance
from PHC Medical Directors and Grievance & Appeal Nurse
- Investigates member-disputes of denied benefits/services,
collects new evidence, reassesses
for coverage, executes final decisions, and communicates it to all
- Investigates member-reported concerns about dissatisfactory
experiences while seeking care.
Identifies facts, surveys the health care system, corrects root
causes, and communicates
outcomes to all stakeholders.
- Communicates with members throughout the investigation, offers
solutions, and practices exemplary customer service to all
stakeholders. Frequent contact
with internal departments, providers, third party administrators,
- Manages assigned cases so they are completed within DHCS
timeframes, according to G&A
Desktop procedures, and/or as directed by management.
- Documents all casework activity thoroughly, accurately, timely,
- Writes DHCS and NCQA compliant letters to members and
- Provides leadership to the grievance support team to complete
sub-components of the
- Effective communicator in all modes of communication (e.g.,
- Knows all PHC Medi-Cal benefits or has the ability to master
understanding of all benefits.
Maintains knowledge of PHC Medi-Cal Handbook, PHC Policy &
Procedures, and DHCS
guidelines affecting benefits.
- Identifies systematic or recurring issues that create barriers
to high quality healthcare and
reports them to leadership.
- May serve as backup to absent Grievance & Appeals Case
- Attends meetings as needed including but not limited to Case
Conferences, Case Forum
Meetings, Department Meetings, and Division Meetings.
- Other duties as assigned.Qualifications:Education and
Bachelor's degree or four (4) years of related work experience,
Grievances & Appeals, health care customer service, case management
health plan operations.
Special Skills, Licenses and Certifications
Ability to solve problems, be a critical thinker and detail
with managed care concepts, operations, policies and procedures,
but not limited to knowledge of grievance and appeal regulations.
knowledge of Microsoft Word, Excel, and Outlook. Bilingual skills
Spanish, Tagalog, or Russian preferred, but not required. Valid
driver's license and proof of current automobile insurance
PHC policy are required to operate a vehicle and travel for
Performance Based Competencies
Excellent oral and written communication skills. Ability to
and independent judgment. Must be able to handle multiple tasks and
deadlines. Strong organizational skills with ability to prioritize
work. Must be
able to work in a fast-paced environment, work well under pressure,
maintain professional composure when interacting with all
Work Environment And Physical Demands
Daily use of telephone and computer. More than 70% of work time is
front of a computer monitor. Standard cubical workstation. When
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; and
- Abide by the HealthPlan's policies and procedures, as they may
from time to time be
IMPORTANT DISCLAIMER NOTICE
The 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.
Keywords: Partnership HealthPlan of California, Redding , Grievance and Appeals Case Analyst, Professions , Redding, California
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