Appeals and Grievance Specialist Champion Health Plan Long Beach, CA Job Details Full-time From $25 an hour 9 hours ago Benefits Health insurance Dental insurance 401(k) Paid time off Vision insurance Life insurance Qualifications Spanish Customer communication Medicare Managed care Caseload management HIPAA Research Utilization management Attention to detail Productivity software Healthcare software applications Full Job Description Job Summary Specialist, Appeals & Grievances Champion Health Plan Long Beach, CA | Full-Time | On-Site Job Summary The Appeals & Grievances Specialist is responsible for the intake, research, documentation, and timely resolution of Medicare Advantage appeals, grievances, and member complaints in accordance with Centers for Medicare & Medicaid Services (CMS) requirements and Champion Health Plan policies and procedures. Essential Duties and Responsibilities Receives, reviews, researches, and processes Medicare Advantage appeals, grievances, and complaints. Accurately classifies cases and ensures completion within applicable CMS regulatory timeframes. Researches member concerns using available benefit, authorization, clinical, provider, and other relevant information. Coordinates with Member Services, Utilization Management, Quality, Compliance, Provider Services, Pharmacy, and other departments as needed. Identifies and escalates expedited requests, access-to-care concerns, quality-of-care issues, and other time-sensitive matters. Prepares accurate case summaries, acknowledgment letters, resolution letters, and other required correspondence. Communicates with members, authorized representatives, providers, and internal departments as necessary to investigate and resolve cases. Maintains complete and accurate case documentation and tracks cases through resolution. Assists with CMS audits, regulatory reviews, and internal case-file audits. Identifies complaint trends and potential systemic issues and escalates them to management. Maintains confidentiality and complies with

HIPAA, CMS

requirements, and Champion Health Plan policies. Performs other duties as assigned. Required Qualifications Minimum four (4) years of experience in managed care, a health plan, appeals and grievances, member services, utilization management, or a related healthcare environment. Knowledge of Medicare Advantage and CMS appeals and grievance requirements preferred. Bilingual Spanish/English preferred. Strong written and verbal communication skills. Strong research, analytical, organizational, and problem-solving skills. Ability to manage multiple cases and meet regulatory deadlines. Strong attention to detail and documentation accuracy. Proficiency with Microsoft Office and healthcare information systems. Preferred Qualifications Direct Medicare Advantage Appeals & Grievances experience. Experience with CMS regulatory requirements, audits, or compliance activities. Experience working within a Medicare Advantage health plan, medical group, IPA, or managed care organization. Work Location This is a full-time, on-site position in Long Beach, California .

Pay:

From $25.00 per hour Expected hours: 40.0 per week

Benefits:

401(k) Dental insurance Health insurance Life insurance Paid time off Vision insurance

Experience:

Managed care: 4 years (Preferred)

Medicare:

3 years (Preferred)

Language:

Spanish (Preferred)

Work Location:

In person