Job Description

Our client, a well-funded and well-established non-profit providing pension and health benefits to entertainment industry professionals is seeking to hire a licensed LVN or RN to join their dynamic and collegiate team of professionals at their corporate offices in Burbank. This position will be remote during the pandemic.

GRIEVANCE & APPEALS COORDINATOR

The Grievance & Appeals Administrator will provide direction to claims staff regarding claims processing policies and procedures. Use independent judgment and discretion to review and resolve complex claim issues. Review, analyze, investigate, and make liability decisions and approvals for the release of benefit payment on utilization management files. Examine and process health insurance claims and service calls from physicians, hospitals and customers, as required. Adhere to claim and call policies and procedures while making accurate claim/call decisions. Research and resolve escalated and complex claim issues and maintain documentation associated with processing and handling of appeals to comply with regulatory standards and timeframes. Identify error trends and notify appropriate areas for correction, communicating/educating the necessary parties. Participates in data gathering and analysis of reports regarding appeal activity, as well as, prepares for appeal audits, monitors QI (Quality Improvement) activities of appeals team, and assists in the development of designated Claim staff, department flows and implementations.

KNOWLEDGE, SKILLS, ABILITIES:

• Ability to accurately and efficiently process claims and provide complete information by using the right methods/tools
• Individual must be reliable, dependable, and punctual
• Ability to effectively balance workload in a fast-paced work environment
• Ability to solve problems systematically, using sound business judgment
• Medical Coding
• Ability to work independently in a team environment
• Strong organization skills

REQUIREMENTS:

• High School graduate or equivalent required, and Associates degree or Bachelor’s degree in a health- related field preferred
• Preferred active licensure as an LVN or RN
• Minimum of 4 years’ experience working in a health care grievance & appeals capacity identifying and resolving member complaints, grievances and appeals required
• Preferred credentials and or familiarity working with HEDIS and/or NCQA certified
• Utilization Review / Utilization Management
• Worked in a call center, claims department, and/or other customer service position required
• Strong knowledge of health benefits plans, policies and procedures
• Demonstrated organizational and time management skills
• Strong phone contact handling skills and active listening
• Proficient with Microsoft products, including Word and Excel
• Proven verbal and written communication skills

Equal Opportunity Employer considering qualified candidates in accordance with state and federal laws, including those with criminal histories, in a manner consistent with the City of Los Angeles’ Fair Chance Initiative for Hiring Ordinance.

Company Description

Details to be discussed during phone interview.