Grievance Resolution Specialist
The Judge Group Inc.

Orange, California

Posted in IT


This job has expired.

Job Info


Location: Orange, CA
Description: Our client is currently seeking a Grievance Resolution Specialist in Orange, CA.


Job Summary

This position will coordinate the grievance and appeal resolution process, respond to verbal and written grievances and appeals from members and/or providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, pharmacy and vision decisions.

Position Responsibilities

  • Maintains adequate information and ensures data collection, summarization, integration, and reporting which includes case creation and management and events/activity tracking.
  • Gathers pertinent information regarding the grievance(s) and appeals(s), including, but not limited to, member or provider concern, supporting information related to initial decision, new information supporting the grievance or appeal, supplemental information required to evaluate grievance and appeal within regulatory requirements.
  • Coordinates and/or participate in case discussion with operational experts to result in a final case disposition as needed.
  • Evaluates case details, proposes recommendation or makes a decision as applicable; ensures organization decision is implemented according to the Grievance and Appeals policies and case resolution.
  • Develops resolution letters and correspondence to members and providers.

Possess the Ability To:

  • Communicate effectively with all levels of staff, external stakeholders and members.
  • Exercise discretion in processing confidential information.
  • Identify critical issues and make recommendations or decisions by using critical thinking skills. Document and present case research findings; formulate resolution letters.
  • Effectively utilize computer and appropriate software (i.e. Microsoft Office Suite or related databases).

Experience & Education:

  • High school diploma or equivalent required.
  • 1+ year of experience in any the following areas; appeals and grievances, claims, regulatory compliance, customer service or related fields required.

If you are interested, please call Brittany at 720-449-7546 or send a current resume to bkirking@judge.com.

Contact: bkirking@judge.com

This job and many more are available through The Judge Group. Find us on the web at www.judge.com


This job has expired.

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