Member Service Representative

Job Description

Job Description

Duration: Contract (6+ Months)

Key Responsibilities:

• Maintain working knowledge of regulatory guidelines surrounding Grievances per CMS, DHCS, and DMHC.
• Understand Member and Provider legal rights to access the Grievance and Appeals Resolution Process, within the respective Provider Organization and IEHP.
• Ensure compliance with the IEHP Grievance and Appeals Resolution Process, in accordance with all Health Plan regulatory agencies.
• Responsible for providing administrative support to ensure grievance and appeal cases are processed per regulatory guideline and internal department protocol including:
• Coordinate, document and track all IEHP Member and Provider grievances and appeals.
• Generates written correspondence to Providers, Members, and regulatory entities using appropriate grammar and punctuation.
• Ensure all appropriate grievance and appeal letters are sent out within regulatory compliance guidelines.
• Assist IEHP personnel in filing, tracking, and closing Member and Provider grievances.
• When designated to intake cases, the Grievance and Appeals Coordinator will ensure the following:
• Assign new cases as received for medical urgency and assign to appropriate Grievance Team Member for investigation and resolution.
• Alert assigned Team Member to any immediate needs, provide guidance regarding depth of investigation, best investigative approach, and manner of documentation, such as close oral case as a "1-day” (no written notification required), obtain verbal or written response from provider as indicated, or resolve internally with no provider input required.
• Act as a liaison between IEHP departments to coordinate information and close grievances and appeals within regulatory timelines.
• Keep the Grievance and Appeals Supervisor aware of "open” & "pending” grievance/appeal issues and expected resolution measures.
• Maintain and prepare grievance and appeals summary reports, as needed.
• Assist IEHP management in the assessment of grievance and appeal information for the potential change to IEHP policies and procedures.
• Responsible for working with Team Members to support the protocols and goals of the department and the vision of the organization.
• Demonstrate a commitment to incorporate LEAN principles into daily work.
• Speak to health plan members as needed to clarify or obtain any information necessary in order to process a Grievance or an Appeal appropriately.
• Speak to health plan members as needed to answer any questions regarding their case.

Education & Requirements:

• Bilingual (English/Spanish) - written and verbal skills required
• Three or more (3+) years of administrative experience in an office environment, including use of Microsoft Office Suite
• Demonstrated superior interpersonal and administrative skills commensurate with years of experience
• Experience in a managed care Member Service/Customer Service environment
• Prior Medi-Cal and Medicare experience helpful
• Previous experience documenting and resolving Member and Provider grievances and appeals
• High school diploma or GED required
• Bachelor's degree from an accredited institution preferred

Key Qualifications:

• Understanding of and sensitivity to multi-cultural community
• Excellent communication and interpersonal skills
• Strong organizational skills, typing 45 words per minute, proficient in Microsoft Word and Excel, and data entry experience are essential
• Telephone courtesy
• Ability to handle multiple tasks
• Strong attention to detail and ability to prioritize work to ensure adherence to task deadlines
• Ability to learn and follow standards and procedures
• Positive Attitude and ability to work in a team setting
• The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture
• A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

\nCompany Description

22nd Century Technologies, Inc. (TSCTI) is one of the fastest-growing IT Services Integrators and Workforce Solutions providers in the United States. Founded in 1997, TSCTI is a Certified National Minority Business Enterprise (MBE) with a workforce of 6,000+ professionals, including 600+ Cybersecurity Subject Matter Experts (SMEs), delivering mission-critical solutions across all 50 U.S. states, Canada, and Mexico.

Headquartered in Princeton, NJ, and McLean, VA, with 14 regional offices nationwide, TSCTI provides comprehensive solutions in Digital Transformation, Artificial Intelligence (AI), Cybersecurity, Cloud Computing, IT Infrastructure, Enterprise Modernization, DevSecOps, Managed Services, Workforce Solutions, and Healthcare Staffing. We are a trusted partner to Federal, State, Local, Education (SLED), Healthcare, and Commercial organizations, delivering innovative technology and talent solutions that enable our clients to achieve their strategic objectives.

As one of the nation's leading Healthcare Workforce Solutions providers, TSCTI supports federal healthcare systems, Veterans Affairs (VA) Medical Centers, state and local healthcare agencies, hospitals, clinics, laboratories, long-term care facilities, and commercial healthcare organizations. We recruit and place highly qualified healthcare professionals across a wide range of specialties, including physicians, advanced practice providers, registered nurses, allied health professionals, behavioral health specialists, laboratory personnel, pharmacy professionals, and healthcare administrative staff. Our healthcare solutions ensure continuity of care while maintaining the highest standards of clinical excellence and regulatory compliance.

With a strong commitment to quality and compliance, TSCTI operates through CMMI Level 3 (Development & Services) and ISO 9001, ISO 20000, and ISO 27001 certified processes, ensuring consistent service excellence, operational maturity, and information security. Today, we proudly support 14 of the 15 Federal Executive Departments, 37 Federal agencies, 50 State governments, 115+ Local agencies, 37 School Districts, numerous healthcare organizations, and 80+ Fortune 500 and commercial clients.

TSCTI has earned numerous industry recognitions, including being named among Forbes America's Best Large Employers, Forbes Best Employers for Veterans, Forbes Best Employers for Tech Workers, Newsweek's America's Greatest Workplaces for Diversity, and a 13-time Inc. 5000 honoree. The company has also been recognized by the Washington Business Journal as one of the Best Places to Work and continues to expand its capabilities through strategic innovation, acquisitions, and investments in emerging technologies.

At TSCTI, our people are our greatest strength. We are committed to fostering an inclusive, collaborative, and growth-oriented workplace where innovation thrives and careers flourish. Whether delivering cutting-edge technology solutions or connecting exceptional talent with meaningful careers, we consistently exceed our clients' expectations while empowering our employees to succeed.

Equal Opportunity Employer

22nd Century Technologies, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Company Description

22nd Century Technologies, Inc. (TSCTI) is one of the fastest-growing IT Services Integrators and Workforce Solutions providers in the United States. Founded in 1997, TSCTI is a Certified National Minority Business Enterprise (MBE) with a workforce of 6,000+ professionals, including 600+ Cybersecurity Subject Matter Experts (SMEs), delivering mission-critical solutions across all 50 U.S. states, Canada, and Mexico.\r\n\r\nHeadquartered in Princeton, NJ, and McLean, VA, with 14 regional offices nationwide, TSCTI provides comprehensive solutions in Digital Transformation, Artificial Intelligence (AI), Cybersecurity, Cloud Computing, IT Infrastructure, Enterprise Modernization, DevSecOps, Managed Services, Workforce Solutions, and Healthcare Staffing. We are a trusted partner to Federal, State, Local, Education (SLED), Healthcare, and Commercial organizations, delivering innovative technology and talent solutions that enable our clients to achieve their strategic objectives.\r\n\r\nAs one of the nation's leading Healthcare Workforce Solutions providers, TSCTI supports federal healthcare systems, Veterans Affairs (VA) Medical Centers, state and local healthcare agencies, hospitals, clinics, laboratories, long-term care facilities, and commercial healthcare organizations. We recruit and place highly qualified healthcare professionals across a wide range of specialties, including physicians, advanced practice providers, registered nurses, allied health professionals, behavioral health specialists, laboratory personnel, pharmacy professionals, and healthcare administrative staff. Our healthcare solutions ensure continuity of care while maintaining the highest standards of clinical excellence and regulatory compliance.\r\n\r\nWith a strong commitment to quality and compliance, TSCTI operates through CMMI Level 3 (Development & Services) and ISO 9001, ISO 20000, and ISO 27001 certified processes, ensuring consistent service excellence, operational maturity, and information security. Today, we proudly support 14 of the 15 Federal Executive Departments, 37 Federal agencies, 50 State governments, 115+ Local agencies, 37 School Districts, numerous healthcare organizations, and 80+ Fortune 500 and commercial clients.\r\n\r\nTSCTI has earned numerous industry recognitions, including being named among Forbes America's Best Large Employers, Forbes Best Employers for Veterans, Forbes Best Employers for Tech Workers, Newsweek's America's Greatest Workplaces for Diversity, and a 13-time Inc. 5000 honoree. The company has also been recognized by the Washington Business Journal as one of the Best Places to Work and continues to expand its capabilities through strategic innovation, acquisitions, and investments in emerging technologies.\r\n\r\nAt TSCTI, our people are our greatest strength. We are committed to fostering an inclusive, collaborative, and growth-oriented workplace where innovation thrives and careers flourish. Whether delivering cutting-edge technology solutions or connecting exceptional talent with meaningful careers, we consistently exceed our clients' expectations while empowering our employees to succeed.\r\n\r\nEqual Opportunity Employer\r\n\r\n22nd Century Technologies, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.