Job Description

As a healthcare organization dedicated to providing quality services to the Central Coast community, our client is seeking a highly motivated individual to join their team. The ideal candidate will be committed to the mission of improving the health and well-being of members of the community and will bring a combination of skills, experience, and passion to the role.

Under the supervision of the Grievance & Appeals Manager, the Grievance & Appeals Administrative Specialist is responsible for the administrative initiation, tracking, and resolution of member grievances, appeals, and billing issue cases. This individual plays a key role in ensuring accurate documentation, thorough investigation, and timely resolution of all assigned cases while maintaining compliance with regulatory and contractual standards. The role requires a high level of attention to detail, sound judgment, and strong written and verbal communication skills to ensure exceptional service recovery and member satisfaction.

Key Responsibilities:

• Review and analyze member dissatisfaction cases, using documentation from Member Services and Behavioral Health Call Center teams to determine appropriate classification and next steps
• Collaborate with the Clinical Improvement Specialist and Grievance & Appeals Manager to accurately categorize and route cases for review or escalation
• Manage end-to-end case processing for grievances and appeals with incomplete information, ensuring timely resolution and final communication to members within required time frames
• Monitor grievance intake channels daily (online system, call tracking, fax, mail, and in-person submissions) to ensure proper documentation and assignment
• Investigate and manage member billing issues, maintaining compliance with provider review timelines and contractual obligations
• Support the Grievance & Appeals Manager in ensuring complete and accurate documentation for all member grievances and billing cases
• Participate in cross-departmental meetings with Behavioral Health, Compliance, Provider Relations, and Quality teams to discuss trends, updates, and process improvements
• Assist in the preparation and organization of case files for internal and regulatory audits
• Identify opportunities for process improvements and provide feedback to enhance documentation, communication, and resolution workflows

Qualifications:

• 2–3 years of experience in a healthcare administration, managed care, or related setting involving grievances, appeals, or complex billing resolution
• Associate degree (AA) or equivalent combination of education and relevant experience
• Strong critical thinking and analytical skills for case research and problem-solving
• Ability to multi-task, prioritize, and make sound decisions within established guidelines
• Excellent oral and written communication skills, with a customer service-oriented approach
• Ability to work independently with minimal supervision and maintain accuracy under pressure
• Demonstrated proficiency with Microsoft Office Suite (Word, Excel, Windows, Adobe Acrobat)
• Familiarity with key system screens including Oracle Member Grievance, Claim Adjudication, Utilization Management, Provider Network, and related tools (Cisco Agent Desktop, Veritas, CalWIN, RightFax)
• Experience in Medi-Cal or managed care environments preferred
• Knowledge of data collection and analysis methods preferred
• Understanding of conflict resolution and problem-solving techniques preferred
• Prior exposure to regulatory or audit preparation processes preferred
• Necessary Systems & Screens: HIS Oracle Member Grievance, COG Claim Adjudication, Standard Reports (SRR), Utilization Management, Provider Network, Procedure Configuration, Cisco Agent Desktop, Veritas, CalWIN, RightFax

Compensation:

• Hourly Range: $23.30 – $27.96 - $32.62

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