Medicare​/Medicaid Service Specialist ( Grievance​/Appeals - Bilingual

Title: Medicare / Medicaid Service Specialist ( Grievance / Appeals - Bilingual )

Location: Orange, CA 92868

Mode: Onsite

Job Type: Contract (6+ months)

Pay Range: $23.92-$33.49/hr

• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Serves as the point of contact within or outside Cal Optima Health for inquiries related to grievances and appeals.
• Monitors incoming complaints via the Customer Service system routing, interdepartmental referral, mail, telephone, fax or via email from the website for members and providers.
• Monitors inquiry requests from the Department of Managed Health Care (DMHC), Medicare Complaint Tracking Module (CTM) from the Centers for Medicare Medicaid Services (CMS), Medicare Quality Improvement Organization (QIO) and the State Hearing Office from Department of Social Services (DSS).
• Responds to DMHC requests for information in a timely manner.
• Sets up complaint case files, enters cases in the GARS system with accurate classification and category types and assigns them to appropriate staff.
• Works with internal and external departments and providers in gathering supporting information relevant to the case.
• Generates acknowledgment letters for all lines of business per department and regulatory standards.
• Assists in the development of departmental forms and intake processes.
• Coordinates administrative support for state hearings, serves as a contact with DSS for incoming cases, enters cases in the GARS system, creates electronic files and routes the scanned documents to designated staff and fax required state hearing documentation to the local hearing office as necessary.
• Completes other projects and duties as assigned.

• High School diploma or equivalent required PLUS 1 year of experience in appeal and grievance guidelines or Medi-Cal/Medicaid or Medicare programs required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

• Bilingual in English and in one of defined threshold languages (Arabic, Chinese, Farsi, Korean, Spanish, Vietnamese).