An Eligibility Specialist provides assistance and information for people who apply for a government benefits program or health care program. Answers questions, assists with an application process, and reviews applications and relevant background information to determine eligibility. May assist eligible applicants with enrolling in a program.
Job Summary We are seeking a detail-oriented and customer-focused Grievance & Appeals Coordinator to join our healthcare team. In this role, you will manage the end-to-end resolution of member and provider grievances and appeals, ensuring cases are processed accurately, efficiently, and in compliance with state and federal regulations. You will research complex issues, communicate with members, providers, and internal departments, prepare case documentation, and help ensure regulatory timelines are consistently met. •Temporary assignment between 3-6 months•
Schedule:
Hybrid (8:30am-5pm) What you'll be doing Manage the end-to-end processing of member and provider grievances and appeals, ensuring timely, accurate resolution in compliance with state, federal, and organizational requirements. Review, research, investigate, and document grievance and appeal cases, including obtaining medical records and supporting information from members, providers, and delegated entities. Monitor case progress and regulatory deadlines, ensuring timely acknowledgments, correspondence, resolution letters, and implementation of case outcomes. Prepare case files, statements of position, and supporting documentation for State Fair Hearings, Independent Review Entities (IREs), and other escalated appeal processes. Maintain complete and accurate case documentation within internal systems while meeting audit, regulatory, and departmental quality standards. Communicate professionally with members, providers, and internal departments to resolve complex issues, provide case updates, and support positive outcomes. Identify operational trends, participate in case audits, and collaborate with cross-functional teams to improve processes and support departmental initiatives. Provide backup support for grievance and appeals intake, participate in meetings and special projects, and represent the organization during hearings and other grievance-related proceedings as needed What you'll need High school diploma or GED required; Associate's degree or equivalent education, training, or experience preferred. Minimum of two years of experience in customer service, provider services, health services, or pharmacy within a managed care or healthcare environment handling complex or escalated issues. Knowledge of health plan benefits, managed care operations, and commercial, Medi-Cal, and/or Medicare programs. Strong analytical, organizational, and problem-solving skills with the ability to research issues, prioritize multiple cases, and consistently meet regulatory timelines. Excellent verbal and written communication skills with the ability to professionally interact with members, providers, internal teams, and external stakeholders while de-escalating sensitive situations. Proficiency with Microsoft Office Suite (Outlook, Word, Excel) and experience accurately documenting and maintaining case information within computer systems. Ability to exercise sound judgment, maintain strict confidentiality, and adapt to changing priorities in a fast-paced environment. Bilingual skills in Spanish, Vietnamese, Chinese, or Tagalog are a plus.
Jonathan Secondary Pay:
$32.00 - $35.00 per hour Application Question(s): Do you have knowledge of health plan benefits, processes, and operations? Are you proficient with Microsoft Office suite? Do you have experience with health insurance, Medi-cal or Medicare programs?
Education:
High school or equivalent (Required)
Experience:
Customer service, health service, or managed care: 2 years (Required)
