Temporary Grievance & Appeals Case Analyst

Job description

Overview Represents Partnership in the Grievance & Appeals Resolution process. Responsible for reviewing,investigating, and resolving assigned member grievance and appeal cases ranging from low tohigh complexity. Works to transform member dissatisfaction into member satisfaction. Overseesthe investigative process ensuring casework complies with DHCS guidelines, NCQA standards,and Partnership best practices. Works independently, provides leadership on each investigation,prioritizes case deliverables, remains customer-focused, and stays current on changes in thehealthcare system that may trigger member dissatisfaction. Responsibilities: - Independently determines best resolution on assigned cases, incorporating clinical guidancefrom Partnership Medical Directors and Grievance & Appeal Nurse Specialists. - Investigates member-disputes of denied benefits/services, collects new evidence, reassessesfor coverage, executes final decisions, and communicates it to all stakeholders. - Investigates member-reported concerns about dissatisfactory experiences while seeking care.Identifies facts, surveys the health care system, corrects root causes, and communicatesoutcomes to all stakeholders. -...