Appeals & Grievances Case Manager

Immediate need for a talented Appeals & Grievances Case Manager. This is a 06+months contract opportunity with long-term potential and is located in Riverside, CA (Onsite). Please review the job description below and contact me ASAP if you are interested.

Job ID:26-05594

Pay Range: $20 - $23/hour.  Traveler benefits as per agency package. (Benefits vary by vendor and assignment.).

Key Responsibilities:

• Manage full lifecycle of appeals and grievances (intake → investigation → determination → closure)
• Review denied claims, benefit disputes, and quality of care concerns
• Draft clear, compliant determination letters (CMS, DMHC, NCQA)
• Collaborate with RNs, Medical Directors, Utilization Management, and Compliance teams
• Ensure all cases meet regulatory turnaround times (TAT)
• Maintain accurate, audit-ready documentation
• Communicate with members and providers regarding case status and outcomes

Key Requirements and Technology Experience:

• 5+ years of experience in Appeals & Grievances / Utilization Management / Case Management
• Strong experience with member appeals (NOT just billing or call center)
• Experience working with health plans (Kaiser, Aetna, Blue Shield, Molina, etc.)
• Strong knowledge of CMS, DMHC, NCQA guidelines
• Proven experience writing appeal/determination letters
• Ability to manage high-volume caseloads with strict deadlines
• Experience with Medicare, Medi-Cal, and Commercial plans

Our client is a leading Pharmaceutical 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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