Note: The job is a remote job and is open to candidates in USA. Kforce Inc is seeking a Customer Support Specialist to join their team in a remote capacity, with candidates required to reside in California. The primary function of the role is to learn and support the appeals and grievances process, ensuring positive outcomes for members by resolving complaints and appeals while adhering to relevant standards and regulations.

Responsibilities

• Primary function of this role is to learn the specialty level appeals and grievances work by resolving less complex cases to ensure positive outcomes for members (20%)
• Supports the identification, investigation and resolve administrative complaints, simple appeals while adhering to Center for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MRMIB) and National Committee for Quality Assurance (NCQA) standards and regulations (20%)
• Intakes, acknowledges, prepares case files and routes complaints to appropriate internal departments and external business partners for investigation and resolution, exercising strong independent judgment (20%)
• As assigned process accurately and in a timely manner the assigned cases; Escalates complex issues or questions to leadership as appropriate (20%)
• Actively participates in team meetings and provide recommendation for improvement as appropriate based on discoveries (10%)
• Performs other duties as assigned (10%)

Skills

• High School diploma/or High School Equivalency Certificate
• Associate's degree
• 1+ years of experience in Managed Care working with Medicare, Medi-Cal and other State Sponsored programs
• Experience working with firm deadlines, able to interpret and apply regulations
• Must be organized, detail oriented, able to exercise strong independent judgment; poses conflict resolution and persuasion skills
• A team player with excellent communication and presentation skills, able to work effectively with various internal departments/service areas, plan partners, participating provider groups and other external agencies
• Proficient in MS Office applications including Word, Outlook and Excel
• Ability to provide confidentiality and professional customer service skills
• Ability to work under tight deadline
• Strong analytical, verbal, written and presentation skills, able to monitor and be compliant with strict regulatory deadlines
• Knowledge of Medical terminology and strong advocacy experience
• In-depth knowledge of DHCS, NCQA, CMS, DMHC regulatory and guidelines

Benefits

• Medical/dental/vision insurance
• HSA
• FSA
• 401(k)
• Life, disability & ADD insurance to eligible employees
• Salaried personnel receive paid time off
• Hourly employees are not eligible for paid time off unless required by law
• Hourly employees on a Service Contract Act project are eligible for paid sick leave

Company Overview