Grievances and Appeals Manager

You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients. Job Summary Our client is seeking a dedicated Grievances and Appeals Manager responsible for conducting clinical reviews, engaging with providers, and presenting findings to drive decisions for enrollee cases. The role includes professional correspondence in compliance with regulatory standards.

Key Responsibilities Clinical Review:

Analyzing cases with prior denials to determine enrollee eligibility.

Provider Outreach:

Contacting provider offices to request additional medical information.

Committee Presentation:

Presenting findings to the Appeals and Grievances Committee virtually.

Professional Correspondence:

Drafting resolution letters adhering to regulatory guidelines. Qualifications Must be a Registered Nurse (RN). Bachelor's degree preferred; acceptability of Associate degree is under review. Experience with health plans, specifically in Appeals & Grievances or Quality. Fast learners with the right foundational experience are encouraged to apply. Skills Familiarity with Medicaid or CMS regulations is preferred. Strong communication and organizational skills. Benefits Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances). Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)). 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1). Short Term Disability Insurance. Term Life Insurance Plan. Required Employment / Compliance Language Medix is committed to providing equal employment opportunities and complying with all applicable federal, state, and local laws. This job description is intended to describe the general nature and level of work being performed by individuals assigned to this position. It is not intended to be an exhaustive list of duties, responsibilities, and skills required for this position. Medix reserves the right to make exceptions to these requirements as necessary. • We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).

Medix Overview:

With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we're dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours. • As a job position within our Insurance division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing medical and confidential records, verifying financial information, and working within departments that care for vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients