[Hiring] Health Plan Case Manager – Appeals & Grievances @Pyramid Consulting

Role Description

Immediate need for a talented Health Plan Case Manager – Appeals & Grievances (California). This is a 06+ Months Contract opportunity with long-term potential and is located in US (Remote).

We are seeking a detail-oriented Case Manager – Appeals & Grievances to:

• Investigate, coordinate, and resolve member complaints, grievances, and appeals in compliance with health plan and regulatory standards.
• Ensure timely and fair resolutions.
• Maintain accurate documentation.
• Facilitate strong cross-functional collaboration.

Qualifications

• 2+ years experience in Appeals, Grievances or Care Coordination in a health plan or TPA.
• Strong understanding of CMS, DMHC, and NCQA regulatory standards.
• 5+ years of Appeals & Grievances experience within a Health Plan or Managed Care organization.
• Excellent written communication skills.
• Experience reviewing medical records and clinical documentation.

Requirements

• Experience handling Member Appeals.
• Experience handling Provider Appeals.
• Experience with Claims Denials.
• Experience with Authorization Appeals.
• Experience with Benefit Determinations.
• Knowledge of CMS, DMHC, NCQA, Medicare, Medi-Cal, and Commercial Health Plans.

Benefits

• Pay Range: $27 - $30/hour.
• Traveler benefits as per agency package. (Benefits vary by vendor and assignment.)