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:26-05594Pay Range: $20 - $27/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 concernsDraft clear, compliant determination letters (CMS, DMHC, NCQA)Collaborate with RNs, Medical Directors, Utilization Management, and Compliance teamsEnsure all cases meet regulatory turnaround times (TAT)Maintain accurate, audit-ready documentationCommunicate with members and providers regarding case status and outcomesKey Requirements and Technology Experience:5+ years of experience in Appeals & Grievances / Utilization Management / Case ManagementStrong 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 guidelinesProven experience writing appeal/determination lettersAbility to manage high-volume caseloads with strict deadlinesExperience with Medicare, Medi-Cal, and Commercial plansOur 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.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, colour, 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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