Grievance And Appeals Coordinator

Urgently hiring a REMOTE Grievances and Appeals coordinator that MUST sit out of SLO, Santa Barbara or Ventura County.

Must have:

• At least 2 years of grievance and appeals experience in a managed care setting
• MUST sit out of San Luis Obispo, Santa Barbara or Ventura County.

Description

This position will provide for the facilitation of member grievances and appeals (G&A) and member billing issue cases as assigned by the MS Grievance and Appeals QI Manager. This position must be committed to service recovery and perform at a high-level regarding research, resolution and strong verbal and especially written communication skill set meeting all regulatory and contractual requirements.

The Grievance and Appeals (G&A) Coordinator must demonstrate a thorough understanding of CenCal Healths benefits and any applicable coordination of benefits. This position must have a thorough knowledge and understanding of applicable copayments and coinsurance with other healthcare coverage, pharmacy formulary, provider network and appropriate interactions with local government and CBO agencies.

Duties and Responsibilities

Maintain assigned G&A and member billing case load along with appropriate overview of G&A documentation of member grievance and appeal descriptions from Call Center team and contact with members should description not provide needed information for the appropriate categorization of G&A cases for Health Services review and approval

Initiate investigation, research, prepare clinical G&A packets for Health Services QI nurse and Medical Director, and resolution of G&A cases that do not require clinical professional review and outcome for Grievance Managers review and approval

Provide final letter to members within mandated resolution time frames and complete G&A packet for Grievance & QI Supervisors review and approval

Assure compliance with Health Plans G&A Policies and Procedures which are aligned with government regulations and laws

Provide high-level customer service through the appropriate and accurate in-depth research and resolution of member grievances, appeals, billing issues including those complex cases and retro cases from state referrals that require in-depth knowledge of provider claims submission and benefit understanding within established & mandated service levels. The G&A Coordinator is fluent with reference databases and has the ability to handle a high volume of cases within the specified periods

Provide feedback to Member Services Call Center Managers regarding appropriate and complete documentation for the Member Grievance and Appeal System

Establish and maintain effective and cooperative working relations with internal health plan staff, outside collaborative agencies such as DSS, Public Health Department, Tri-Counties

Regional Centers, California Childrens Services, Public Authority, Alcohol Drug and Mental

Health for SB County and Mental Health Services for SLO County, Social Security Administration and network providers

Provide support and investigative assistance regarding State Fair Hearings to the Director of Member Services and Director of Legal Affairs

Skills

windows, managed care, Medi-cal, billing research, benefits investigation, health plan

Top Skills Details

windows,managed care,Medi-cal,billing research,benefits investigation,health plan

Additional Skills & Qualifications

Required:

Demonstrate a thorough understanding of CenCals various healthcare program benefits, Share of Cost, eligibility, coordination with other health care coverage, coordination with the local government and CBO agencies, PMB, Pharmacy formularies specific to individual Program benefits and understanding of the Plan Provider Network requirements necessary for the resolution of member grievance and appeals and member billing issues. This position must have extensive knowledge of hospital, physician and provider office protocols, medical record requests, research and investigative skills necessary for the appropriate clinical review of appeal and quality of care cases

Must have the ability to multi-task

Demonstrate good judgment in making decisions within the scope of the position

Ability to work independently with minimal supervision

Excellent oral and written communication skills

For those bilingual positions, must be fluent in Spanish per testing results by Plan consultant

Must be able to demonstrate a complete knowledge of the Plan HIS screens noted below while meeting established service standards for resolution times, accuracy, Customer Satisfaction and the ability to take on special projects as assigned by the Grievance & QI Manager and/or Director

Experience Level

Intermediate Level

This is a Contract position based out of Santa Barbara, CA.

The pay range for this position is $30.51 - $32.61/hr.

Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: Medical, dental & vision Critical Illness, Accident, and Hospital 401(k) Retirement Plan Pre-tax and Roth post-tax contributions available Life Insurance (Voluntary Life & AD&D for the employee and dependents) Short and long-term disability Health Spending Account (HSA) Transportation benefits Employee Assistance Program Time Off/Leave (PTO, Vacation or Sick Leave)

This is a fully remote position.

This position is anticipated to close on Oct 9, 2026.

About TEKsystems

We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change. That's the power of true partnership. TEKsystems is an Allegis Group company.

The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

About TEKsystems and TEKsystems Global Services

Were a leading provider of business and technology services. We accelerate business transformation for our customers. Our expertise in strategy, design, execution and operations unlocks business value through a range of solutions. Were a team of 80,000 strong, working with over 6,000 customers, including 80% of the Fortune 500 across North America, Europe and Asia, who partner with us for our scale, full-stack capabilities and speed. Were strategic thinkers, hands-on collaborators, helping customers capitalize on change and master the momentum of technology. Were building tomorrow by delivering business outcomes and making positive impacts in our global communities. TEKsystems and TEKsystems Global Services are Allegis Group companies. Learn more at TEKsystems.com.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

San Francisco Fair Chance Ordinance: Pursuant to the San Francisco Fair Chance Ordinance, for all positions located in the city and county of San Francisco, we will consider for employment qualified applicants with arrest and conviction records.

Massachusetts Lie Detector: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Use of Artificial Intelligence (AI): We may use Artificial Intelligence (AI) to support parts of our hiring process, including sourcing, screening, and evaluating candidates. AI helps assess applications and qualifications, but final decisions are made by our hiring team. By applying, you acknowledge and agree that your application may be reviewed using AI tools.