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Grievance Resolution Specialist Job Description Department(s): Grievance & Appeals Resolution Services (GARS) Reports to: Manager, Grievance & Appeals FLSA status: Non-Exempt Salary Grade: F - $51,000 - $78,122 Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on Wednesday, November 15, 2023 at 11:59 PM. Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. About CalOptima Health CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! About the Position The Grievance Resolution Specialist will be responsible for coordinating the Grievance and Appeal resolution process, respond to verbal and written Grievances and Appeals from members and/or providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, pharmacy and vision decisions. The incumbent will have frequent external contact with members and families, health care providers, health networks, third party administrators and regulators. The incumbent will collaborate with internal departments such as Customer Service, Provider Operations, Pharmacy and Medical Management to identify factors necessary for the optimal resolution of Grievances and Appeals. Duties & Responsibilities: 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. Maintains adequate information in CalOptima Health's systems; ensures data collection, summarization, integration and reporting which includes case creation and management and events/activity tracking. Gathers pertinent information regarding the grievances and appeals received including but not limited to member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal, or supplemental information required to evaluate grievances and appeals within regulatory requirements. Coordinates and/or participates in case discussion with operational experts to result in a final case disposition as needed. Evaluates case details, proposes recommendations or makes decisions as applicable; ensures organization decision is implemented according to the Grievance and Appeals policies and case resolution. Develops resolution letters and correspondence to members and providers. Communicates with internal and external customers to ensure timely review and resolution of grievances or appeals. Initiates referrals to Quality Improvement department as applicable and facilitates responses to members according to CalOptima Health policy. Assists with health networks' compliance process. Identifies trends and root cause of issues, proposes solutions or escalates ongoing issues to management. Meets performance measurement goals for Grievance and Appeals Resolution Services. Completes other projects and duties as assigned. Experience & Education: High School diploma or equivalent required. 1 year of experience in any of the following areas: Grievances and Appeals, Claims, Regulatory Compliance, Customer Service or related fields required. An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying. Preferred Qualifications: Associate's degree in Business, Health Care Administration or related field. Experience in health care practice standards, for both government and commercial plans. Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese). Physical Demands and Work Environment: The physical demands and work environment characteristics 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. Physical demands: While performing duties of job, employee may be required to move about the organization and to travel to offsite locations. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Must also be able to reach with hands and arms and must occasionally lift office supply boxes or laptop case while traveling, up to 25 pounds. Employee must be able to communicate, particularly for regular phone use, in meetings, face-to-face interaction and while presenting. Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures. Work is performed at workstation; there are steps and elevators available to access the work areas. All floors have keypad controls for the safety of the employee. About our Benefits & Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. Job Location: Orange, California Position Type: To apply, visit https://jobs.silkroad.com/CalOptima/Careers/jobs/4337 Copyright 2022 Jobelephant.com Inc. All rights reserved. Posted by the FREE value-added recruitment advertising agency jeid-2f5c90f8df0a9c49a7a77df2ffbf3e20

Grievance Resolution Specialist, Sr. (Provider Resolution) Job Description Department(s): Grievance & Appeals Resolution Services (GARS) Reports to: Manager Grievance & Appeals FLSA status: Non - Exempt Salary Grade: H - $59,000 - $89,782 Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on Friday, December 1, 2023 at 11:59 PM. Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. About CalOptima Health CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! About the Position Are you looking for a career that changes lives? As the single largest health plan in Orange County, CalOptima Health serves one in three residents with health insurance programs for low-income children, adults, seniors and people with disabilities. Our 1,500 employees are valued for their individual perspectives and contributions and benefit from flexible work schedules, recognition and opportunities to grow. If you're looking for a rewarding career supporting a meaningful mission, along with generous benefits and recognition, consider joining us at CalOptima Health! Position Responsibilities: 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. Develops and maintains adequate information systems to assure timely and effective data collection, summarization, integration and reporting, including but is not limited to case creation, management and events/activity tracking. Ensures compliance with CalOptima Health's Grievance Policy and timely case resolution e.g., initiates and coordinates referrals to the Quality Improvement department as necessary and facilitates response to members according to policy. Gathers pertinent information regarding complaints, including, but not limited to, member or provider concerns, claims payments, billing reimbursements, supporting information related to initial decisions, new information supporting complaints and supplemental information required to evaluate complaints and regulatory requirements. Coordinates and participates in case discussions with operational experts to result in a final case disposition. Independently reviews Government Claim Cases and determines resolution and recommendation based on researched claims, Provider Dispute Resolution (PDR) and 2nd Level Appeal analyses. Evaluates case details related to member or provider complaints and makes appropriate decisions based on information provided and research conducted. Provides a summary of GARS cases requested by Legal Affairs or other departments. Trains new and existing staff, assists in case assignment, takes on case assignment per business needs and oversees the day-to-day operations for member and provider complaints and monitors for compliance in implementation of the decision. Contacts appropriate parties to request and obtain missing information and supporting documentation or provides education. Oversees resolution letters for accuracy of information and appropriate decisions. Meets performance measurement goals for GARS. Attends meetings on issues related to case assignments as well as meetings with various departments to keep up to date understanding of organizational processing and guidelines to effectively resolve cases. Reads and interprets provider contracts, Division of Financial Responsibility (DOFR), policies, procedures and instructions. Responds to routine provider inquiries via phone and assists with provider appeals resolution inquiries. Handles escalated issues from providers, as well as internal and external customers. Tracks and trend provider appeals and claims issues. Supports all department initiatives in improving overall efficiency. Assists with provider appeals audits by reviewing findings, gathering and organizing requested materials and completing rebuttals. Completes other projects and duties as assigned. Experience & Education: High School diploma or equivalent required. 3 years of experience with Provider Non-Contracted Medicare Post-Service appeals and denials required. 3 years of experience with PDR in Medicare and Medi-Cal in Professional, Institutional, Outpatient, Ancillary, Coordination of Benefits and Government Cases required. Experience with Medicare or Medi-Cal provider appeals and denials process required. Experience in health care practice standards, for both government and commercial plans required. Experience with Claims Administration required. An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying. Preferred Qualifications: Associate's degree in Health Care Administration or related field. Physical Demands and Work Environment: The physical demands and work environment characteristics 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. Physical demands: While performing duties of job, employee may be required to move about the organization. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Must also be able to reach with hands and arms and must occasionally lift office supply boxes or laptop, up to 25 pounds. Employee must be able to communicate, particularly for regular phone use, in meetings, face-to-face interaction and while presenting. Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures. About our Benefits & Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. Job Location: Orange, California Position Type: To apply, visit https://jobs.silkroad.com/CalOptima/Careers/jobs/4443 Copyright 2022 Jobelephant.com Inc. All rights reserved. Posted by the FREE value-added recruitment advertising agency jeid-e6d60332798d9b4eaaf4b779b8ec9bae

job description SENIOR EMPLOYEE RELATIONS SPECIALIST CHIEF INVESTIGATOR HUMAN RESOURCES DIVISION - EMPLOYEE RELATIONS SECTION Salary Range: $ 84,396 - $ 123,379 About Us The Los Angeles City Attorney's office is one of the nation's largest municipal law offices. With over 1,000 legal professionals, including 500 attorneys, the Office provides the City with the highest caliber of legal services, ranging from prosecuting criminal misdemeanors and playing a leading role in criminal justice reform, advising on homelessness initiatives, defending civil lawsuits and claims, and bringing civil enforcement actions in the name of the People of the State of California. Guided by an overarching commitment to integrity, accountability and transparency, we find great meaning in the work we do and the services we provide. Human Resources is responsible for all human resources and personnel functions for employees of the Office of the City Attorney. The Employee Relations Section handles formal and informal employee complaints, investigates complaints, handles grievances, disputes, and disciplinary maters ensuring fair treatment and compliance with City Policies and employment laws. This position is open to those with investigative experience preferably in human resources or employee relations. We also offer competitive benefits and flexible work schedules, including telework. Duties and Responsibilities The Senior Employee Relations Specialist will work under the supervision of Human Resources and the Employee Relations Supervisor. The responsibilities of the position include: ? Assisting Managers and Supervisors in employee related maters to ensure resolution and compliance with City policy. ? Liaising with Management and Labor Relations to ensure compliance of all labor and employment laws. ? Meeting with supervisors or senior managers to discuss investigation summary, outcomes and recommended action related to employee complaints. ? Assisting management in resolving or preventing workplace conflicts, grievances and disagreements by creating action plans to address problem areas where disparate treatment/impact is identified. ? Provides training, advice and counsel to supervisors, employees and OHR Generalists on employee relations’ issues. ? Conducting highly complex and sensitive personnel and administrative investigations; ? Interviewing witnesses, involved employees, custodians of records, and public and private persons who may be represented by their Union or legal counsel; ? Securing facts and developing evidence from all sources, including the collection of physical evidence to establish the extent and nature of violations being investigated; ? Researching applicable labor and employment laws, Memoranda of Understanding, rules and procedures of Employee Relations Boards, City of Los Angeles Administrative Code, City of Los Angeles Charter and the Office’s past practices; ? Preparing detailed, clear, and concise reports and recommendations related to personnel maters, grievances and complaints; ? Managing several investigations simultaneously and providing information, as needed, on the status of investigations; ? Presenting the results of investigations to the Human Resources Director and Assistant Director, Employee Relations Supervisor, Labor Relations Division and thereafter, to the Executive Office; ? Testifying at court and administrative proceedings as needed; ? Developing and maintaining department policies & procedures; ? Developing and maintaining an efficient tracking system for cases assigned to them. ? Supporting management in performance management maters, grievance and Skelly processes; ? Processing terminations. Reviewing, drafting, and revising administrative notices, other documents and correspondence at the request of the Human Resources Director regarding personnel maters; ? Assisting in other HR functions if needed; and ? Performing other special projects and duties as assigned. Requirements Applicants must have: ? A minimum of five (5) years conducting investigations in the following areas: personnel, employment law, alleged fraud, auditing or monitoring of employee discipline, internal affairs, EEO, discrimination violations or evidentiary hearings; ? The ability to prepare detailed, clear and concise reports; ? Skill in monitoring and controlling the confidentiality of human resources files and reports; ? Skill in interviewing attorneys and represented parties. ? Skill in establishing and maintaining effective working relations with co-workers, member of the public and representatives from other local, state and federal agencies; ? Skill in reading, interpreting, understanding and applying personnel standards and procedures, applicable rules and regulations, and office policies and procedures; ? Strong oral and written communication skills; and ? Experience utilizing a PC with common software applications. Desired Qualifications The following qualifications are highly desirable: ? Knowledge of applicable state and federal statutes, rules, codes and regulations; ? Knowledge of principles of Human Resources Management; ? Experience working in Human Resources/Personnel; ? Knowledge of City of Los Angeles’ personnel policies, rules and procedures of the Employee Relations Boards, City of Los Angeles Administrative Code, City of Los Angeles Charter and Memoranda of Understanding; ? Knowledge of principles and practices of employee relations, supervision, safety, worker’s compensation, Affirmative Action, personnel administration and training; and ? Law degree or legal background. Writing Sample Applicants are required to submit a writing sample of a recent investigative report. Benefits Offered Medical, Dental, Vision Life Insurance Disability Insurance Tax-Advantage Spending Accounts Retirement Plan (LACERS) Deferred Compensation Plan (457(b)) Employee and Family Assistance Program Paid Time Off 13 Yearly Holidays Vacation Personal Leave Floating Holidays Sick Leave Bereavement Leave Telework This position may qualify for up to 3 days of telework per week. Current Location City Hall East, 200 N. Main Street, Los Angeles. Position is subject to assignment at any location within the County of Los Angeles. COVID-19 Vaccine Requirement For candidates seeking initial City employment, in accordance with Los Angeles City Ordinance 187134, information regarding COVID -19 vaccination requirements as conditions of employment may be found at: htps://clkrep.lacity.org/onlinedocs/2021/21-0921_ord_187134_8-24-21.pdf Probation Appointment to this exempt position (non-Civil-Service) will be subject to a one (1) year probationary period as required by Section 1050 of the City Charter. Successful completion of the one (1) year probationary period will result in tenure with the office. Conflict of Interest This position is designated as Category 14 on the Conflict of Interest Code. Contact Questions? Please email atty.recruit@lacity.org. How to apply Application and Deadline Interested applicants should submit a cover letter, writing sample and resume in one (1) merged PDF file specifying SENIOR EMPLOYEE RELATIONS SPECIALIST - HUMAN RESOURCES #3291 B to Atty.Recruit@lacity.org by MONDAY, DECEMBER 4, 2023. Interested applicants who have applied in the last 6 months do not need to resubmit an application. Qualified applicants will be invited to interview. exempt employment If employment is said to be exempt, it is meant that the employment is exempted from the civil service provisions of the City Charter. In order to receive a regular civil service appointment, employees must have successfully participated in a civil service examination, received a high enough score on the examination to be placed on and receive an appointment from an eligible list, and they must serve a probationary period. Exempt employees do not compete in a civil service examination, they are not placed on an eligible list and receive an appointment from that list, nor do they serve a probationary period. As a result, exempt employees do not have what is referred to as a “property interest” in their job. Exempt employees serve at the will of the appointing authority and can be terminated at any time without cause. Employees with a property interest in their job, i.e. civil service employees, cannot be deprived of their employment(discharged or suspended) without due process. General Information About Exempt Employment Exempt employees serve at the will of the appointing authority, and as such, they may be discharged, suspended or otherwise disciplined without cause. Exempt employees have no property interest in their employment, and any procedural benefit or other prerogative extended to them by their appointing authority is not intended to create and does not create any such property interest. No officer or employee of the City may make to any other officer or employee any representation of a property interest in employment which does not correspond to Charter provisions unless the City Council, by ordinance, permits such representation. No unauthorized representation can serve as the basis of an employee's reliance on, or expectation of, a property interest. Employees Seeking To Become Civil Service Employees There is no protective leave for an exempt employee appointed to a civil service position. Upon receiving a civil service appointment and passing probation, the former exempt employee will be subject to the Civil Service provisions described in Article X of the City Charter. Upon appointment, the civil service employee will begin to accrue displacement and layoff seniority on the first day of his/her civil service appointment and may file for promotional examinations for which s/he qualifies. A full or half-time exempt employee appointed to a full or half-time civil service position continues to: contribute to the Retirement System; accrue vacation time; accrue sick time; receive anniversary date salary increases; and, receive health and dental benefits identical to those received in the civil service position. For candidates seeking initial City employment, in accordance with Los Angeles City Ordinance 187134, information regarding COVID-19 vaccination requirements as conditions of employment may be found at: https://clkrep.lacity.org/onlinedocs/2021/21-0921_ord_187134_8-24-21.pdf . Closing Date/Time: 12/4/23