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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