Training Program Coordinator (Grievance and Appeals)

Training Program Coordinator (Grievance and Appeals)

CalOptima

CalOptima Health is seeking a highly motivated an experienced Training Program Coordinator (Grievance and Appeals) to join our team. The Training Program Coordinator will provide grievance and appeals specialized tasks relevant to an assigned programs and projects. The incumbent will design, develop and effectively deliver a training program for Grievance & Appeals (GARS) staff. The incumbent will be responsible for auditing grievance and appeal activity performed with the GARS department following regulatory and internal guidelines in conjunction with CalOptima Health policies and procedures. The incumbent will review quality assurance results and provide member and provider grievance and appeals training based on internal and external audit results. The incumbent will provide general trend information to management. The incumbent will provide assistance to the Office of Compliance department with internal audits and Centers for Medicare & Medicaid Services (CMS), Department of Health Care Services (DHCS) or Department of Managed Health Care (DMHC) audits, as well as research and distribute updates based on regulatory guidelines. The incumbent will have specialized background or knowledge regarding grievance, appeals, provider dispute resolution, authorization rules, claims processing and division of financial responsibility and regulatory guidelines relevant to grievance and appeals. The incumbent will often work independently, performing research and administrative duties. The incumbent will exercise discretion and judgment and may coordinate a function and the work of others within the program/project.

Position Information:

Department: Grievance & Appeals

Salary Grade: H - $59,000 - $89,782

Work Arrangement: Partial Telework

**This position is eligible for telework in California.**

Duties & Responsibilities:

80% - Program Support

Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.

Develops and maintains a comprehensive training program and conducts new hire training.

Conducts training audits using CalOptima Health approved tools that are consistent with all regulatory, contractual and accrediting standards and requirements.

Analyzes and reviews case files to determine if the appropriate case classified was utilized based on regulatory guidelines.

Develops reporting and trending for management.

Analyzes and reviews case files to determine if cases were resolved within the required regulatory timeframe.

Analyzes and reviews case files to determine if the case was handled appropriately based on regulatory and internal guidelines in conjunction with CalOptima Health policies and procedures.

Analyzes and reviews grievance and appeal resolution letter(s) to determine if all member or provider complaints were identified and resolved appropriately.

Analyzes and reviews grievance and appeal letters to ensure appeal language is appropriate to each line of business and complaint type was accurately utilized.

Audits all decisions that have been overturned to determine if they have been effectuated timely and accurately.

Conducts oversight of the day-to-day grievance & appeals processes for new hires.

Conducts training on changes to workflow(s) based on departmental updates and based on errors identified during internal and external audits.

Determines on-going training needs as well as identify cross-training opportunities.

Provides feedback (report card) to new staff on opportunities for improvement.

Compiles, summarizes and provides recommendations for improvement based on audit results to the upper management.

Works closely with management to identify any training, system or workflow opportunities related to member grievance and appeals and provider grievances, disputes and appeals.

15% - Administrative Support

Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.

Develops, updates and maintains desktop level procedures.

Serves as a liaison between GARS, Office of Compliance and Regulatory Affairs for regulatory updates, provides updates during weekly/monthly meetings and conducts trainings on the changes as needed.

5% - Completes other projects and duties as assigned.

Minimum Qualifications:

High School diploma or equivalent required.

2 years of health care management experience, preferably in managed care environment in related area of responsibility (i.e., customer service, member grievances and appeals and/or provider grievances and appeals) required.

HMO, Medicare, Medi-Cal/Medicaid and health services experience 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.

Preferred Qualifications:

Bachelor's degree.

Experience in training in a managed care environment.

Experience in development and presentation of training tools and materials.

Medicare and Medi-Cal customer service and claims experience.

Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).

Required Licensure / Certifications:

N/A

Knowledge & Abilities:

Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.

Work independently and exercise sound judgment.

Communicate clearly and concisely, both orally and in writing.

Work a flexible schedule; available to participate in evening and weekend events.

Organize, be analytical, problem-solve and possess project management skills.

Work in a fast-paced environment and in an efficient manner.

Manage multiple projects and identify opportunities for internal and external collaboration.

Motivate and lead multi-program teams and external committees/coalitions.

Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Physical Requirements (With or Without Accommodations):

Ability to visually read information from computer screens, forms and other printed materials and information.

Ability to speak (enunciate) clearly in conversation and general communication.

Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.

Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.

Lifting and moving objects, patients and/or equipment 10 to 25 pounds

Work Environment:

If located at the 500, 505 Building or a remote work location:

Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.

There are no harmful environmental conditions present for this job.

The noise level in this work environment is usually moderate.

If located at PACE:

Work is typically indoors in a clinical setting serving the frail and elderly.

There may be harmful or hazardous environmental conditions present for this job.

The noise level in this work environment is usually moderate to loud.

If located in the Community:

Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.

Employee will occasionally work outdoors in varied temperatures.

There may be harmful or hazardous environmental conditions present for this job.

The noise level in this work environment is usually moderate to loud.

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 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. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the ;/strong> regarding our comprehensive benefits and wellness package.

IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS

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 April 11, 2024 at 9:00 PM (PST). 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.

The selection process may include, but is not limited to, a skills assessment, phone screen and interview.

The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet.

Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application.

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 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 at 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.

To apply, please visit: ;/strong>

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