Case Manager Appeals & Grievances (California)
Immediate need for a talented Case Manager ā Appeals & Grievances (California). This is a 06 months contract opportunity with long-term potential and is located in CA(Remote). Please review the job description below and contact me ASAP if you are interested.
Job ID:25-95299
Pay Range: $20 - $25/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).
Key Responsibilities:
ā¢ Manage and investigate member appeals and grievances related to denied services, benefits, billing issues, or care concerns
ā¢ Review medical records, claims, policies, and guidelines to determine appropriate case outcomes
ā¢ Draft accurate, compliant written determinations within CMS, DMHC, and NCQA turnaround requirements
ā¢ Collaborate with providers, utilization management, compliance, clinical quality, and operations teams to collect necessary documentation
ā¢ Track case progress, maintain logs, and ensure cases meet quality, accuracy, and timeliness metrics
ā¢ Communicate case status and requirements to members, providers, and internal departments
ā¢ Support audits, reporting, quality reviews, and process improvement initiatives
ā¢ Protect member confidentiality and follow HIPAA, regulatory, and organizational standards
Key Requirements and Technology Experience:
ā¢ Key skills; Appeals & Grievances case handling experience
ā¢ Knowledge of CMS, DMHC, NCQA regulatory requirements
ā¢ Medical records and claims review
ā¢ Drafting written determinations and case summaries
ā¢ Case management systems (A&G systems, UM platforms, CRM)
ā¢ Strong written and verbal communication
ā¢ Ability to manage high-volume caseloads
ā¢ Healthcare plan or TPA environment experience
ā¢ 2 years of experience in Appeals & Grievances, Utilization Management, Care Coordination, or Health Plan Operations
ā¢ Strong knowledge of CMS, DMHC, NCQA regulations
ā¢ Experience reviewing medical records, claims, and policy guidelines
ā¢ Excellent written and verbal communication skills
ā¢ Ability to manage high-volume caseloads accurately and efficiently
ā¢ Experience with case management systems and Microsoft Office
ā¢ Must be able to work remote; candidates within 1 hour of Corona, CA preferred
Our client is a leading Healthcare Industry and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.
Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
By applying to our jobs you agree to receive calls, AI-generated calls, text messages, or emails from Pyramid Consulting, Inc. and its affiliates, and contracted partners. Frequency varies for text messages. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. You can reply STOP to cancel and HELP for help. You can access our privacy policy here.
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Job ID:25-95299
Pay Range: $20 - $25/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).
Key Responsibilities:
ā¢ Manage and investigate member appeals and grievances related to denied services, benefits, billing issues, or care concerns
ā¢ Review medical records, claims, policies, and guidelines to determine appropriate case outcomes
ā¢ Draft accurate, compliant written determinations within CMS, DMHC, and NCQA turnaround requirements
ā¢ Collaborate with providers, utilization management, compliance, clinical quality, and operations teams to collect necessary documentation
ā¢ Track case progress, maintain logs, and ensure cases meet quality, accuracy, and timeliness metrics
ā¢ Communicate case status and requirements to members, providers, and internal departments
ā¢ Support audits, reporting, quality reviews, and process improvement initiatives
ā¢ Protect member confidentiality and follow HIPAA, regulatory, and organizational standards
Key Requirements and Technology Experience:
ā¢ Key skills; Appeals & Grievances case handling experience
ā¢ Knowledge of CMS, DMHC, NCQA regulatory requirements
ā¢ Medical records and claims review
ā¢ Drafting written determinations and case summaries
ā¢ Case management systems (A&G systems, UM platforms, CRM)
ā¢ Strong written and verbal communication
ā¢ Ability to manage high-volume caseloads
ā¢ Healthcare plan or TPA environment experience
ā¢ 2 years of experience in Appeals & Grievances, Utilization Management, Care Coordination, or Health Plan Operations
ā¢ Strong knowledge of CMS, DMHC, NCQA regulations
ā¢ Experience reviewing medical records, claims, and policy guidelines
ā¢ Excellent written and verbal communication skills
ā¢ Ability to manage high-volume caseloads accurately and efficiently
ā¢ Experience with case management systems and Microsoft Office
ā¢ Must be able to work remote; candidates within 1 hour of Corona, CA preferred
Our client is a leading Healthcare Industry and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.
Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
By applying to our jobs you agree to receive calls, AI-generated calls, text messages, or emails from Pyramid Consulting, Inc. and its affiliates, and contracted partners. Frequency varies for text messages. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. You can reply STOP to cancel and HELP for help. You can access our privacy policy here.
#St
Apply Now
Apply Now