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Description

A Medical IPA Group in Los Angeles is in the immediate need of a Grievance & Appeals Specialist. The Grievance & Appeals Specialist, will be in responsible for investigating, documenting, and resolving denied claims, complying with State/Federal laws, rules, and guidelines. The Grievance & Appeals Specialist will be expected to perform research and utilize your extensive knowledge of claims to respond to inquiries and interpret plan/policy provisions. This role offers excellent training and benefits.

Responsibilities:

• Investigate, document, and resolve denied claims in accordance with State/Federal laws, rules, and guidelines.

• Perform research to respond to inquiries and interpret plan/policy provisions.

• Write determination letters regarding the outcome of non-clinical reviews/claim denials and send to the applicable participant/provider.

• Research incoming correspondence related to claim denials and determine the necessary next steps.

• Assist with research to advise management on medical claims issues and assist with developing guidelines for use by examiners or Participant Services Representatives.

• Assist Appeals Coordinator with the preparation of Benefits Committee appeal cases.

• Develop guidelines for examiners to use in evaluating whether certain types of claims may require review and other medical claims issues.

• Work with legal counsel on cases as directed by Management.

• Provide guidance to Participant Services Representatives on calls regarding medical claims issues.

• Recommend changes to management on Health Plan language for medical benefits.

Requirements

• Minimum of 2 years of experience as a Medical Claims Review Coordinator or in a similar role

• Proficient in handling Medical Claims and Medical Appeals

• Experience with EMR - Electronic Medical Records is mandatory

• Strong knowledge of Basic Medical Terminology

• Proven track record in handling Appeals and Medical Grievances

• Excellent coordination and organization skills

• Ability to work under pressure and meet deadlines

• Strong attention to detail and problem-solving skills

• Excellent communication and interpersonal skills

• Ability to work independently and as part of a team

• High level of integrity and professionalism

Robert Half is the world’s first and largest specialized talent solutions firm that connects highly qualified job seekers to opportunities at great companies. We offer contract, temporary and permanent placement solutions for finance and accounting, technology, marketing and creative, legal, and administrative and customer support roles.

Robert Half works to put you in the best position to succeed. We provide access to top jobs, competitive compensation and benefits, and free online training. Stay on top of every opportunity - whenever you choose - even on the go. Download the Robert Half app (https://www.roberthalf.com/us/en/mobile-app) and get 1-tap apply, notifications of AI-matched jobs, and much more.

Robert Half will consider for employment qualified applicants with arrest or conviction records in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. All applicants applying for U.S. job openings must be legally authorized to work in the United States. Benefits are available to contract/temporary professionals, including medical, vision, dental, and life and disability insurance. Hired contract/temporary professionals are also eligible to enroll in our company 401(k) plan. Visit roberthalf.gobenefits.net for more information.

• 2025 Robert Half. An Equal Opportunity Employer. M/F/Disability/Veterans. By clicking “Apply Now,” you’re agreeing to Robert Half’s Terms of Use (https://www.roberthalf.com/us/en/terms) .