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Grievance & Appeals Case Analyst

Partnership HealthPlan of California • Fairfield, CA, US • published 2026-10-02 15:58:45.732235

Description

Overview: Represents Partnership in the Grievance \& Appeals Resolution process. Responsible for reviewing, investigating, and resolving assigned member grievance and appeal cases ranging from low to high complexity. Works to transform member dissatisfaction into member satisfaction. Oversees the investigative process ensuring casework complies with DHCS guidelines, NCQA standards, and Partnership best practices. Works independently, provides leadership on each investigation, prioritizes case deliverables, remains customer\-focused, and stays current on changes in the healthcare system that may trigger member dissatisfaction. Responsibilities: * Independently determines best resolution on assigned cases, incorporating clinical guidance from Partnership Medical Directors and Grievance \& Appeal Nurse Specialists. * Investigates member\-disputes of denied benefits/services, collects new evidence, reassesses for coverage, executes final decisions, and communicates it to all stakeholders. * Investigates member\-reported concerns about dissatisfactory experiences while seeking care. Identifies facts, surveys the health care system, corrects root causes, and communicates outcomes to all ...

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