Customer Solution Center Appeal and Grievance Compliance Advisor

Overview

Customer Solution Center Appeal and Grievance Compliance Advisor is a full-time position with CCG Talent Management. CCG Business Solutions has been consulting and providing talent placement services since 2007. We are currently recruiting for a Customer Solution Center Appeal and Grievance Compliance Advisor.

• The Customer Solution Center Audit Readiness Specialist II is responsible for the execution, oversight, and monitoring of the guidelines and protocols to ensure readiness for all regulatory audits.
• Develop, with CSC management, an auditing strategy for end-to-end processes within CSC (including enrollment processing timeliness and accuracy of loading members, timeliness of  and member materials, outbound health risk assessment calls for Seniors and People with Disabilities (SPD) and Cal Medi Connect (CMC) plus HIF for L.A. Care Medi-Cal Direct program (MCLA), call documentation and categorization, service authorization requests and coverage determinations, Appeals and Grievances across all lines of business).
• Lead ongoing progression and maintenance of CSC's compliance program, including policy and procedure development, training and education initiatives, and compliance programmatic developments and enhancements.
• Complete targeted, focused and random audits related to member interactions and outcomes to ensure compliance; present results with management and recommend corrective actions.
• Be responsible for regulatory obligations for each line of business and governing bodies (California Department of Health Care Services, Department of Public Social Services, Centers for Medicare and Medicaid Services, LACC - Cal Hers, NCQA) and review and analyze regulatory requirements for all product lines; lead audit situations, present and report full findings, and ensure action plans are created, executed, and verified through reconciliation of end-to-end regulatory functions.
• Perform audit readiness activities: identify issues, develop criteria, review evidence, document processes; conduct interviews, reviews, surveys, create memos and working papers; document audit issues and recommendations; communicate results to CSC management; collaborate with business units in audit universe preparation and validation; assist in document preparation for regulatory and internal audits.
• Regulatory compliance: work with CSC Management to determine effectiveness/accuracy of operational processes; collaborate with internal SMEs to understand regulatory processes and identify root causes of deficiencies; evaluate policies and procedures against regulations and provide recommendations for continuous improvements.
• Collaborate with the Customer Solution Center Business Analyst to track, trend, and analyze QA scorecards for training and quality improvement.

• Minimum of 5 years of experience in regulatory auditing (Appeals & Grievances, Call Center, Enrollment) in a healthcare environment.
• Previous experience with Medi-Cal and Medicare in a managed care environment.
• Bachelor's Degree required. In lieu of degree, equivalent education and/or experience may be considered.