grievance and appeals coordinator

Alignment Healthcare

<div><p>Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.</p><p></p>
This position is remote in Orange, CA.<br>
<br>
The Appeals &amp; Grievance Coordinator is responsible for the day-to-day functions of the tracking and trending of all grievances, appeals, and complaints received within the Member Services Department. Acts as the primary investigator and contact person for member and provider grievances and appeals.<p></p><p><b>
GENERAL DUTIES/RESPONSIBILITIES :</b><br>
1. Acknowledges the receipt of all grievance/appeals, and CTM (Complaint Tracking Module).<br>
2. Gathers pertinent and relevant information from the member and/or provider regarding the grievance/appeal, determines the appropriate resolution of the grievance/appeal per standard policies and procedures; and notifies the appropriate parties of the resolution and ensuring that all internal processes are completed to resolve the issue.<br>
3. Composes written correspondence to members in accordance to plan policy and CMS Guidelines.<br>
4. Conducts non-biased, accurate, timely and comprehensive investigation of all the facts related to the grievance/appeal.<br>
5. Thoroughly documents all action taken on behalf of the member or provider to resolve the grievance/appeal.<br>
6. Ensures that all grievances/appeals are processed in adherence to the Centers for Medicare and Medicaid (CMS) guidelines and plan policy.<br>
7. Prepares case files for Medical Director Review and external (including IRE) review of grievances/appeals as appropriate.<br>
8. Prepares clear, objective, accurate and comprehensive case histories for presentation and consideration at committee meetings (including Board of Directors).<br>
9. Maintains accurate and timely documentation, including complete files of all grievances/appeals. Prepares monthly and quarterly reports as requested.<br>
10. Identifies training opportunities and potential system and process improvements relating to grievance/appeal data.<br>
11. Participates in periodic review and update of grievance/appeal policies and procedures to reflect appropriate legal and CMS requirements as well as participate in periodic CMS Audit preparations and regulator meetings/interviews.<br>
12. Other duties as assigned.</p><p></p><p><b>
Job Requirements:</b></p><p><b>
Experience:</b></p><ul><li>Required: Two years&rsquo; experience in data entry and general office background.</li></ul><p>
Three years of customer service experience. Minimum 1 year Member Services or similar experience.</p><ul><li>Preferred: 2 years healthcare or insurance experience in a senior setting.</li></ul><p><b>
Education:</b></p><ul><li>Required: High School Diploma or GED.</li><li>Preferred: Associate degree (A.A.) degree.</li></ul><p><b>
Training:</b></p><ul><li>Required:</li><li>Preferred:</li></ul><p><b>
Specialized Skills:</b></p><ul><li>Required:</li></ul><ul><li>
Knowledge of MediCal and Medicare Managed Care Plans.</li><li>
Ability to Keyboard/Type 40+ words per minute and use the 10-key by touch.</li><li>
Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.</li><li>
Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;</li><li>
Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization.</li><li>
Mathematical Skills: Ability to add and subtract two-digit numbers and to multiply and divide with 10&rsquo;s and 100&rsquo;s. Ability to perform these operations using units of American money and weight measurement, volume, and distance.</li><li>
Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.</li><li>
Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.</li><li>Preferred: Bi-lingual (English/Spanish)</li></ul><p><b>
Licensure:</b></p><ul><li>Required: None</li></ul><p></p><p>
Work Environment:
</p><p>The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.</p><p>
The noise level in the work environment is usually moderate.</p><p>
Essential Physical Functions:</p><p>
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.</p><p></p><p>
1 While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.</p><p>
2 The employee is frequently required to walk; stand; reach with hands and arms.</p><p>
3 The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.</p><p>
4 The employee must occasionally lift and/or move up to 20 pounds.</p><p>
5 Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.</p>
Pay Range: $44,790.00 - $67,185.00<p>
Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.
</p><p></p><p>Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.</p><p></p><ul><li><i>DISCLAIMER: Please</i><i> beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal </i><i>information. Please</i><i> be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at </i><i>https://reportfraud.ftc.gov/#/</i><i>. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health&rsquo;s talent acquisition team, please email </i><i>careers@ahcusa.com</i><i>.</i></li></ul></div>

Appeals & Grievances Coordinator - Remote - Orange, CA

PacificSource Health Plans

<div><h1 class="jobSectionHeader"><b>Looking for a way to make an impact and help people?</b></h1><p></p><p><i>
Join PacificSource and help our members access quality, affordable care!</i></p><p></p><p><b>
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age.</b> PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person&rsquo;s talents and strengths.</p><p></p>
Provide clerical assistance to Appeals and Grievance team in entry and maintenance of case records. Provide high quality customer service to internal and external customers regarding appeals and grievance inquiries. Support member and ensure customer satisfaction.<p></p><p><b>
Essential Responsibilities:</b></p><ul><li>
Process intake of appeals and grievances into the departments tracking database.</li><li>
Monitor incoming documents via fax, web, email, USPS and route to appropriate entity in a timely manner and in accordance with department processes</li><li>
Maintain office supply inventory for the department.</li><li>
Communicate complex information related to A&amp;G rules and regulations, verbally and in writing, to internal and external customers.</li><li>
Effectively capture and transcribe meeting minutes.</li><li>
Work collaboratively in an objective, professional, diplomatic manner with all internal and external customers.</li></ul><p></p><p><b>
Supporting Responsibilities:</b></p><ul><li>
Provide clerical backup for other A&amp;G staff as needed.</li><li>
Meet department and company performance and attendance expectations.</li><li>
Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.</li><li>
Perform other duties as assigned.</li></ul><p></p><p><b>
Work Experience:</b></p><p>
Minimum one year customer service, and/or claims processing, health insurance industry process experience required. Data entry experience preferred.</p><p></p><p><b>
Education, Certificates, Licenses:</b></p><p>
High School Diploma or equivalent required.</p><p></p><p><b>
Knowledge:</b></p><p>
Requires strong research, analytical and data entry skills. Experience using Facets, OnBase, and other software packages used by PacificSource is strongly preferred. Must have basic math skills, the ability to work under strict deadlines, and excellent organizational skills.</p><p></p><p><b>
Competencies:</b></p><p>
Adaptability</p><p>
Building Customer Loyalty</p><p>
Building Strategic Work Relationships</p><p>
Building Trust</p><p>
Continuous Improvement</p><p>
Work Standards</p><p>
Contributing to Team Success</p><p>
Planning and Organizing</p><p></p><p><b>
Environment:
</b></p><p>Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.</p><p></p><p><b>
Skills:</b></p>
Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork<p></p><p><b>
Compensation Disclaimer</b></p><p>
The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.
</p><p><b>Base Range:
</b></p>$32,311.65 - $51,698.64<p></p><h1 class="jobSectionHeader"><b>
Our Values</b></h1><p>
We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:</p><ul><li><p>
We are committed to doing the right thing.</p></li><li><p>
We are one team working toward a common goal.</p></li><li><p>
We are each responsible for customer service.</p></li><li><p>
We practice open communication at all levels of the company to foster individual, team and company growth.</p></li><li><p>
We actively participate in efforts to improve our many communities-internally and externally.</p></li><li><p>
We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.</p></li><li><p>
We encourage creativity, innovation, and the pursuit of excellence.</p></li></ul><p></p><p><b>
Physical Requirements:</b> Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.</p><p></p><p><b>
Disclaimer:</b> This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.</p></div>

Appeals and Grievance Support (Monday-Friday)

Alight Solutions

<div><p>Do you have advanced experience in absence management leadership within appeals?</p><p></p><p>
Amazing Opportunity and Great Place to Work!</p><p></p><p><b>
Our story</b></p><p>
At Alight, we believe a company&rsquo;s success starts with its people. At our core, we Champion People, help our colleagues Grow with Purpose and true to our name we encourage colleagues to &ldquo;Be Alight.&rdquo; We are passionate about connecting purpose with impact. Alight empowers clients to build a healthier and more financially secure workforce by unifying the benefits ecosystem across health, wealth, wellbeing, navigation, and absence management.</p><p></p><p><b>
Our Benefits</b></p><p>
With a comprehensive total rewards package, Alight offers programs and plans that support your mind, body, wallet, and life. Benefits include health, dental and vision coverages starting Day One. Additionally, Alight colleagues enjoy wellbeing programs, retirement plans with contribution matching, generous time off, parental leave, continuing education, and career growth opportunities &ndash; all within a thriving global organization.</p><p></p><p><b>
Flexible Working</b></p><p>
So that you can be your best at work and home, we consider flexible working arrangements wherever possible. Alight has been a leader in the flexible workspace and &ldquo;Top 100 Company for Remote Jobs&rdquo; 6 years in a row.
</p><p></p><p><b>Great Place to Work</b></p><p>
Thanks to the work of every colleague, Alight has received multiple awards of recognition including &ldquo;Great Place to Work&rdquo; for the past 7 years and Fortune&rsquo;s &ldquo;Best Companies to Work For.&rdquo; To learn more about our company culture and awards <b>Click Here.</b></p><p></p><p>
If you, Champion People, seek to Grow with Purpose, and embody the meaning of Be Alight &ndash; We invite you to join our team! Learn more at careers.alight.com.</p><p></p><p><b>
Responsibilities</b></p><ul><li>
Leading LOA, STD, ADA, and/or LTD Appeals service teams.</li><li>
Developing strategy and business plans to deliver market-centric capabilities and processes.</li><li>
Working with broader organization and external parties to identify and gaps and develop a plan to address. Anticipating future trends and challenges, developing and implementing strategies to address opportunities.</li><li>
Assessing and evaluated business/technology partners to integrate products on various platforms. Developing and recommended Claims and Service level strategies and tactics.</li><li>
Demonstrating expertise in accurate Appeals Claim Management.
</li><li>Collaborating with peers and senior leadership to deliver exceptional service.</li><li>
Managing Appeals departmental budget and plan effectively for responsible growth.</li><li>
Enhancing the Claims team through regular business updates to ensure alignment with organizational goals. Fostering a culture of trust within the team.</li><li>
Establishing performance metrics with clear systems of measures and accountabilities that drive results.</li><li>
Ensuring that an effective system of regulatory compliance and internal controls have been maintained. Complying with applicable laws and regulations, and documented procedures that incorporated preventive and defective controls. Partnering with Regulatory Compliance and Risk Committees.</li></ul><p></p><p><b>
Requirements</b></p><ul><li>
Possess advanced education, equivalent work experience, training, or DMEC certification.</li><li>
Have experience of 10 years in claims/appeals and 7 years leadership in absence management.</li><li>
Display qualifications or experience in healthcare, rehabilitation, or a medical field.</li><li>
Hold Lean Six Sigma Certification and or formal Operations Strategy training.</li><li>
Have experience in leadership of a team of Managers within Appeals. This position oversees a total organization or roughly 40 professionals.</li></ul><p></p><p><b>
Application and Interview</b></p><p>
By applying for a position with Alight, you understand that, should you be made an offer, it will be contingent on your undergoing and successfully completing a background check consistent with Alight&rsquo;s employment policies. Background checks may include some or all the following based on the nature of the position: SSN/SIN validation, education verification, employment verification, and criminal check, search against global sanctions and government watch lists, credit check, and/or drug test. You will be notified during the hiring process which checks are required by the position.</p><p></p><p>
Alight requires all virtual interviews to be conducted on video.</p><p></p><p><b>
Our commitment to Inclusion</b></p><p>
We celebrate differences and believe in fostering an environment where everyone feels valued, respected, and supported. We know that diverse teams are stronger, more innovative, and more successful.</p><p></p><p>
At Alight, we welcome and embrace all individuals, regardless of their background, and are dedicated to creating a culture that enables every employee to thrive. Join us in building a brighter, more inclusive future.</p><p></p><p>
As part of this commitment, Alight will ensure that persons with disabilities are provided reasonable accommodations for the hiring process. If reasonable accommodation is needed, please contact alightcareers@alight.com.
</p><p></p><p><b>Equal Opportunity Policy Statement</b></p><p>
Alight is an Equal Employment Opportunity employer and does not discriminate against anyone based on sex, race, color, religion, creed, national origin, ancestry, age, physical or mental disability, medical condition, pregnancy, marital or domestic partner status, citizenship, military or veteran status, sexual orientation, gender, gender identity or expression, genetic information, or any other legally protected characteristics or conduct covered by federal, state, or local law. In addition, we take affirmative action to employ disabled persons, disabled veterans, and other covered veterans.</p><p></p><p>
Alight provides reasonable accommodations to the known limitations of otherwise qualified employees and applicants for employment with disabilities and sincerely held religious beliefs, practices and observances, unless doing so would result in undue hardship. Applicants for employment may request reasonable accommodations/modifications by contacting their recruiter.</p><p></p><p><b>
Authorization to work in the Employing Country</b></p><p>
Applicants for employment in the country in which they are applying (Employing Country) must have work authorization that does not, now or in the future, require sponsorship of a visa for employment authorization in the Employing Country and with Alight.</p><p></p><p>
Note, this job description does not restrict management's right to assign or reassign duties and responsibilities of this job to other entities; including but not limited to subsidiaries, partners, or purchasers of Alight business units.</p><p></p><p>
We offer you a competitive total rewards package, continuing education &amp; training, and tremendous potential with a growing worldwide organization.</p><p></p><p>
Salary Pay Range</p><p></p><p>
Minimum :</p>
110,000.00 USD<p>
Maximum :</p>
130,000.00 USD<p></p><p>
Pay Transparency Statement: Alight considers a variety of factors in determining whether to extend an offer of employment and in setting the appropriate compensation level, including, but not limited to, a candidate&rsquo;s experience, education, certification/credentials, market data, internal equity, and geography. Alight makes these decisions on an individualized, non-discriminatory basis. Bonus and/or incentive eligibility are determined by role and level. Alight also offers a comprehensive benefits package; for specific details on our benefits package, please visit: Wellbeing and Benefits Selector Page - Alight</p><p></p><p><b><br>
DISCLAIMER:</b></p><p><br>
Nothing in this job description restricts management's right to assign or reassign duties and responsibilities of this job to other entities; including but not limited to subsidiaries, partners, or purchasers of Alight business units.</p><p></p>
Alight Solutions provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, creed, sex, sexual orientation, gender identity, national origin, age, disability, genetic information, pregnancy, childbirth or related medical condition, veteran, marital, parental, citizenship, or domestic partner status, or any other status protected by applicable national, federal, state or local law. Alight Solutions is committed to a diverse workforce and is an affirmative action employer.</div>

Claims Operations Director- Appeals-Alight Leave Solutions

Texas Department Of Criminal Justice

<div>
 <ul>
  <li>
   PDate 043026 033233 Location of vacancy: Estelle Unit/Huntsville
  </li>
  <li>
   This website contains only partial information regarding this job posting and application procedures.
  </li>
  <li>
   For complete information regarding minimum qualification requirements, availability of study material, work site visits and TDCJ application instructions, go to www.tdcj.texas.gov. Click on EMPLOYMENT and JOB SEARCH. When applying for this position, please reference TDCJ Job Posting No. 019099E2.
  </li>
 </ul>
</div>


INVESTIGATOR I - Inmate Grievance

Served With Honor LLC

<div><p><b>Location: </b>Remote - US</p><p></p><p><b>
Position Summary:
</b></p><p>The Client Service Support Specialist is responsible for delivering personalized, accurate, and compassionate assistance to clients, their family members, and their caregivers as they navigate complex issues related to support services. The Client Service Support Specialist&rsquo;s goal is to ensure our clients feel heard, valued, and supported, and they will accomplish that goal by responding to inquiries with a balance of efficiency and empathy, ensuring every interaction is meaningful and every concern is met with urgency and understanding.</p><p></p><p><b>
Essential Functions:
</b></p><p>Reasonable accommodations may be made to enable individuals with disabilities to
</p><p>perform the essential functions.
</p><ul><li>Serve as the first point of contact for clients seeking support services, appeals, grievance, social service needs, billing issues, and insurance coverage.
</li><li>Listen actively to client concerns, respond with empathy, and deliver accurate, timely solutions across communication channels (phone, chat, email).
</li><li>Support clients navigating complex issues including appeals and grievance submissions and status updates.
</li><li>Billing discrepancies and insurance coverage clarifications.
</li><li>Community-based SDOH-related referrals.
</li><li>Escalations and compliance-sensitive concerns.
</li><li>Provide warm handoffs to internal specialists or external partners when additional expertise or intervention is needed.
</li><li>Document all interactions clearly and accurately in the CRM system to ensure continuity of care and compliance with policies.
</li><li>Recognize urgent or high-risk issues and escalate appropriately using established protocols.
</li><li>Maintain up-to-date knowledge of service offerings and regulations.
</li><li>Collaborate cross-functionally with internal departments.
</li><li>Participate in quality improvement efforts, team meetings, and feedback sessions to ensure excellent client experience.</li></ul><p></p><p><b>
Knowledge, Skills, and Abilities:</b></p><ul><li>Bachelor&rsquo;s degree required</li><li>A minimum of 3 years of customer experience in a healthcare contact center setting</li><li>Experience in a virtual contact center with digital navigation preferred</li><li>Demonstrated commitment to serving diverse populations with empathy, humility, and respect for cultural differences</li><li>Exceptional verbal and written communication skills, able to simplify complex information with compassion and clarity</li><li>Familiarity with billing processes, insurance plans, appeals, and grievance resolution</li><li>Understanding of Social Determinants of Health (SDOH) and ability to guide clients toward
</li></ul><p>appropriate resources</p><ul><li>Ability to remain calm and professional under pressure, especially when handling escalations</li><li>Demonstrated problem-solving skills and resourcefulness in navigating client needs</li><li>Experience working with HIPAA-regulated data and maintaining client confidentiality</li><li>Comfortable using CRM systems, ticketing platforms and digital communication tools</li><li>Strong organizational skills with attention to detail and follow-through</li><li>Ability to learn new processes and adapt to changes</li><li>Team-oriented, adaptable, and energized by a mission-driven, fast-paced environment</li><li>Use initiative to identify problems and provide solutions</li><li>Exceptional problem-solving and time management skills</li></ul><p></p><p><b>
Served with Honor</b> is an Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex, national origin, age, marital status, disability or any other basis prohibited by law.</p><div></div><p><br>
Compensation Range: $40K - $50K</p></div>

Client Service Support Specialist

L.A. Care Health Plan

<div></div><div><div><div><div><div><div><div><p>Authorization Technician II
</p></div></div></div></div><div><div><div><div><b>Job Category: </b>Clinical
</div></div></div></div><div><div><div><div><b>Department: </b>Utilization Management
</div></div></div></div><div><div><div><div><b>Location:
</b>Los Angeles, CA, US, 90017
</div></div></div></div><div><div><div><div><b>Position Type: </b>Full Time
</div></div></div></div><div><div><div><div><b>Requisition ID: </b>13058
</div></div></div></div><div><div><div><div><div><b>Salary Range:</b> $47,840.00 (Min.) - $57,062.00 (Mid.) - $68,474.00 (Max.)</div><br>
<div></div>
<div>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&rsquo;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.<br>
<br>
Mission: L.A. Care&rsquo;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.<br>
</div><div><div><div><div>Job Summary</div>
</div><div><div>
The Authorization Technician II supports the Utilization Management (UM) Specialist by handling all administrative and technical functions of the authorization process including intake, logging, tracking and status follow-up.</div><br>
<div></div>
<div>The Authorization Technician II collects information required by clinical staff to render decisions, assists the Manager and Director of the Utilization Management department in meeting regulatory time lines by maintaining an accurate database inventory of referral authorizations, retrospective reviews, concurrent reviews and grievance/appeal requests, and prepares UM Activity and Weekly Compliance Reports.</div><br>
<div></div>
<div>In addition, the position performs data entry and processing of referrals/authorizations in the system, authorizes request consistent with auto authorization criteria, maintains confidentiality when communicating member information, and assists with the communication of determinations by preparing template letters for members/ providers, with other duties as assigned.</div>
</div></div><div><div><div>
Duties</div>
</div><div><div>Functional Elements: Technical Support to UM Specialist: Processing of time sensitive authorization and pre-certification requests to meet department timeframes and regulatory requirements; Computer Input: Accurately and completely processing referrals/authorizations and distribute a complete file to UM Specialist within 2 hours of receipt; identify duplicate requests using the claims and verify existing authorization. Independently identifying and appropriately returning to claims or member services any file that is a duplicate to one already processed in the system; appropriately documenting what information was used in making this determination within 4 hours of receipt. Appropriate identification and timely notification of time sensitive requests; appropriately identifying for the staff which you support, request that are priority based on date of receipt and established Turnaround Time criteria for compliance. Accurate filing/maintenance of confidential member information. Creating secure, complete, files. Interface with members, medical personnel and other internal and external agencies; ensure all comply with L.A. Care requirements such as submitting requested information in a timely manner and using the approved Authorization Request form with complete medical information i.e.: ICD 10 codes, CPT, HCPC codes. (35%)</div>
<div></div><div>Assist in the preparation of communication for authorization determinations, including, but not limited to preparing template letters for members and providers (authorization approval, denial, deferral, modification and pay/education). (30%)</div>
<div></div><div>Assist in the technical aspects of the retrospective review process for authorizations and Member or Provider Appeals, including, but not limited to computer data entry, logging, copying, preparing of template letters for communication of appeal determinations to members, providers and partners (appeal uphold or overturn) and filing: Set up GNA files for review, log and keep track all due dates for each file. Inform nurses of a new case received from Grievance and Appeals Specialist.; submit all Grievances and Appeals response letters to Grievances Specialist on daily basis. (20%)</div>
<div></div><div>Support UM Committee and Audit activity via Department performance reporting. Assure the accuracy of reports concerning inventory and department proficiency in maintaining regulatory standards and time frames. (5%)</div>
<div>Perform other duties as assigned. (10%)</div>
</div></div><div><div><div>
Duties Continued</div>
</div></div><div></div><div><div><div>Education Required</div>
</div><div><div>High School Diploma/or High School Equivalency Certificate</div></div></div><div><div><div>
Education Preferred</div>
</div></div><div></div><div><div><div>Experience</div>
</div><div><div><b>
Required:</b></div>
<p>At least 6 months of health care experience.</p><br>
<p></p>
<p>Experience working in a cross functional work environment.</p><br>
<p></p>
<p><b>Preferred:</b></p>
<p>Experience in Medi-Cal managed care.</p><br>
<p></p>
<p>1 year of experience in UM/Prior Authorization.</p>
</div></div><div><div><div>
Skills</div>
</div><div><div><b>
Required:</b></div>
<p>Demonstrated proficiency in Medical Terminology required.</p><br>
<p></p>
<p>Strong verbal and written office communication skills.</p><br>
<p></p>
<p>Proficient with Microsoft Office Suite and Adobe PDF. and</p><br>
<p></p><p>Excellent organizational, interpersonal and time management skills.</p><br>
<p></p><p>Must be detail-oriented and an enthusiastic team player.</p><br>
<div></div>
<div><b>Preferred:</b></div>
<p>Knowledge of QNXT computer systems a plus.</p><br>
<p></p>
<p>Knowledge of the UM patient referral process.</p><br>
<p></p>
<p>Knowledge of member&rsquo;s health plan eligibility.</p><br>
<p></p>
<p>Knowledge of member&rsquo;s benefits coverage.</p><br>
<p></p><p>Knowledge of Health Plan regulations.</p><br>
<p></p>
<p>Knowledge of HMO/UM functions.</p><br>
<p></p>
<p>Knowledge of ICD-10/CPT coding.</p><br>
<p></p><p>Proficient utilizing electronic medical records and documentation programs.</p>
</div></div><div><div><div>
Licenses/Certifications Required</div>
</div></div><div></div><div><div><div>Licenses/Certifications Preferred</div>
</div><div><div>Medical Coding Certification</div></div></div><div><div><div>
Required Training</div>
</div></div><div></div><div><div><div>Physical Requirements</div>
</div><div><div>Light</div></div></div><div><div><div>
Additional Information</div>
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Required:</b></div>
<div>Weekends and holidays hours may be required, as well as OT based on a business need.</div>
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Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.</div><br>
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<div><b>L.A. Care offers a wide range of benefits including</b></div>
<ul><li>Paid Time Off (PTO)</li>
<li>Tuition Reimbursement</li>
<li>Retirement Plans</li>
<li>Medical, Dental and Vision</li>
<li>Wellness Program</li>
<li>Volunteer Time Off (VTO)</li></ul><div><br>
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<b>Nearest Major Market: </b>Los Angeles
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<b>Job Segment: </b>EMR, Claims, Data Entry, Medical Coding, Healthcare, Insurance, Administrative</p></div></div></div><div></div>

Authorization Technician II

Desert Parkway Behavioral Healthcare Hospital

<div><p>Desert Parkway Behavioral Healthcare Hospital is dedicated to delivering compassionate, safe, and high-quality care to our community. We are committed to fostering a culture of safety, continuous improvement, and regulatory excellence. We are currently seeking a dedicated and detail-oriented <b>Clinical Quality and Risk Coordinator</b> to join our team and make a meaningful difference in patient outcomes.</p><p>
The position is responsible for incident investigation, data analytics, regulatory compliance monitoring, and CMS aligned grievance management. This role requires clinical judgment or formal regulatory/quality training to interpret behavioral health events, identify trends, and support organizational risk mitigation strategies.</p><p><b>
KEY RESPONSIBILITIES</b>:</p><p><b>
Clinical/Regulatory Investigation &amp; Analysis</b></p><ul><li>
Conduct clinical‑level incident investigations (self‑harm, elopement, medication events, restraint/seclusion).</li><li>
Perform root cause analyses (RCA, FMEA).</li><li>
Evaluate clinical documentation for accuracy and regulatory compliance.</li><li>
Identify system‑level contributing factors and corrective actions.</li><li>
Collaborate with Nursing, Medical Staff, and Clinical Services on high‑risk events.</li></ul><p><b>
 Data &amp; Trend Analytics</b></p><ul><li>
Analyze incident data using statistical methods.</li><li>
Develop trend reports, dashboards, and risk profiles.</li><li>
Identify emerging patterns requiring intervention.</li><li>
Review and document within the incident reporting application.</li><li>
Present findings to leadership and committees.</li></ul><p><b>
 Regulatory Compliance</b></p><ul><li>
Monitor compliance with CMS, Joint Commission, and state regulations.</li><li>
Support survey readiness and mock tracers.</li><li>
Assist with policy development and regulatory updates.</li></ul><p><b>
Complaint and Grievance Management</b></p><ul><li>
Manage complaint and grievance intake, documentation, and timelines.</li><li>
Ensure CMS‑compliant investigation and written responses.</li><li>
Track complaint and grievance trends and identify systemic issues.</li></ul><br>
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Requirements</b><br>
<ul><li>
Valid Nevada licensure as a Registered Nurse required
</li><li>Certification in healthcare quality, compliance, or risk preferred</li><li>
Minimum three (3) years previous experience in healthcare regulatory compliance, quality, or risk required</li><li>
Hospital experience required; behavioral health clinical experience preferred</li><li>
Previous experience analyzing incident data, developing dashboards and identifying trends required</li><li>
Experience with incident investigation and RCA methodology</li><li>
Experience with survey readiness activities (CMS, Joint Commission, or state)</li><li>
Experience using incident reporting systems and managing data integrity</li><li>
Knowledge of CMS grievance regulations, to include CMS-aligned investigation, documentation, and written responses</li><li>
Ability to interpret clinical documentation and apply regulatory standards</li></ul><br>
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Benefits</b><p><br>
A full benefits package is available the first of the month following just one month of employment.</p><p>
Desert Parkway offers competitive benefits for full-time employees to include:</p><ul><li>
Medical insurance
</li><li>Dental insurance</li><li>
Vision insurance
</li><li>401K Retirement Plan</li><li>
Healthcare spending account</li><li>
Dependent care spending account</li><li>
PTO Plan with holiday premium pay</li><li>
Discounted cafeteria meal plan</li><li>
Life insurance (including plans for spouse and children)</li><li>
Short- and long-term disability (with additional buy-in opportunities)</li><li>
Pet Insurance</li><li>
Identity Theft Insurance</li></ul></div>

Clinical Quality and Risk Coordinator

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