Lead Customer Solution Center Appeals and Grievances

Salary Range:  $67,186.00 (Min.) - $87,342.00 (Mid.) - $107,498.00 (Max.)

 

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
 

Job Summary

The Lead of Customer Solution Center Appeals and Grievances is responsible for assisting with the development of a successful and cohesive Appeals and Grievance unit, with a high level of productivity to achieve the department's overall performance metrics, and to meet and/or exceed member satisfaction. Responsible for the day to day oversight of Appeals and Grievance Specialist by closely monitoring work, providing feedback on performance, trains, coaching, mentoring, motivating, and ensures compliance to policies, procedures and regulations. Ensures that all Appeals and Grievances are processed accurately and timely. 

Duties

Leads day to day activities of the Appeals and Grievances team including but not limited to: Providing direction to the team, handling internal or external questions or issues raised in relation to Appeals or Grievances and recommending and implementing resolution, new processes and or process improvement. Assist Supervisor to ensure that Specialist provide accurate, timely, and quality responses. Ensure that all departmental policies, procedures and standards are being followed in an effort to meet departmental and organizational goals. Assist the Supervisors to ensure that deviations in performance are identified in advance and process changes are made to redirect performance to acceptable levels. Provides accurate and timely written and/or verbal statistical reports that includes historical and/or current data to aid in projecting or evaluating Compliance status. Assist Supervisor in reviewing the Specialists overall quality and accuracy, provide education and training where applicable to remediate reoccurrences. Support and lead the distribution and redistribution of inventory and/or assignments as needed. Ability to accurately process all case types including regulatory cases and to provide recommendations towards resolution.

 

Trains and motivates staff. Ensures appropriate compliance standards are followed and maintained. Work closely with Supervisors to create and/or modify Desk Level Procedures. Leads the work of assigned staff; regularly assigns and checks the work of others, providing guidance, training and feedback on performance to department management.  Oversees the daily office workflow, develops and recommends enhancements to process and procedures. 

 

Work closely with management to review performance and quality standards on an ongoing basis. As well as motivational programs needed to achieve regulatory standards.

 

Acts as a back-up to the Supervisor leading meetings and handling escalations as required.

 

Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval.

 

Performs other duties as assigned.

Duties Continued

Education Required

Associate's DegreeIn lieu of degree, equivalent education and/or experience may be considered.

Education Preferred

Bachelor's Degree

Experience

Required:

At least 4 years of Appeals and Grievance experience and experience working with firm deadlines, able to interpret and apply regulations.

 

At least 1 year of leading process, program, or staff experience.

 

Preferred:

Experience in working with the disadvantage population, Medi-Cal, Covered California, and Cal MediConnect. One year lead experience in a health plan/healthcare.

Skills

Required:
Must have strong knowledge of CMS, DMHC, and DHCS regulations.

 

Must know Medical Terminology.

 

Must have excellent written and verbal communication skills. Possess skillset to effectively communicate with all levels including but not limited to members, peers, leaders, physicians, executives, and regulatory entities.

 

Strong analytical, coaching/mentori