Case Manager – Appeals & Grievances (California)

Immediate need for a talented

Case Manager – 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: Manage and investigate member appeals and grievances related to denied services, benefits, billing issues, or care concerns Review medical records, claims, policies, and guidelines to determine appropriate case outcomes Draft accurate, compliant written determinations within

CMS, DMHC, and NCQA

turnaround requirements Collaborate with providers, utilization management, compliance, clinical quality, and operations teams to collect necessary documentation Track case progress, maintain logs, and ensure cases meet quality, accuracy, and timeliness metrics Communicate case status and requirements to members, providers, and internal departments Support audits, reporting, quality reviews, and process improvement initiatives Protect member confidentiality and follow HIPAA, regulatory, and organizational standards

Key Requirements and Technology Experience:

Key skills; Appeals & Grievances case handling experience Knowledge of CMS, DMHC, NCQA regulatory requirements Medical records and claims review Drafting written determinations and case summaries Case management systems (A&G systems, UM platforms, CRM) Strong written and verbal communication Ability to manage high-volume caseloads Healthcare plan or TPA environment experience 2+ years

of experience in Appeals & Grievances, Utilization Management, Care Coordination, or Health Plan Operations Strong knowledge of

CMS, DMHC, NCQA

regulations Experience reviewing medical records, claims, and policy guidelines Excellent written and verbal communication skills Ability to manage high-volume caseloads accurately and efficiently Experience with case management systems and Microsoft Office 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.

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