Fair Hearing Specialists

Summary

At Gainwell, you can contribute your skills as we harness the power of technology to help our clients improve the health and well-being of the members they serve - a community's most vulnerable. Connect your passion with purpose, teaming with people who thrive on finding innovative solutions to some of healthcare's biggest challenges. Gainwell empowers you to help clients deliver better health and human services outcomes using innovative technology and solutions, enabling you to design your career for growth, new possibilities, and refinement of your valuable skills. This position is responsible for researching and analyzing incoming hearing requests, determining proper procedures to follow, creating supporting documentation, processing claims/TARs on final determinations, communicating with the members, providers and DHCS, and updating the State Hearing System.

Your role in our mission

• Research hearing requests and obtain additional information, if needed. Analyze documents and decides on how to proceed to provide a case reevaluation. Create documentation supporting the determination including determination letters and Position Statements.
• Process claims and TARs based on the final determination of the appeal. Regular updating, tracking, and monitoring of extensive caseload in the State Hearing System (SHS) and Appeals Case Management System (ACMS).
• Regular communication with the members, providers, and DHCS to ensure the appeals are concluded successfully and accurately. Communicate regularly with members, providing extensive support throughout the entire appeals process.
• Perform miscellaneous duties and handle additional requests from the Department of Health Care Services and the Department of Social Services Hearing Division.
• Adhere to all required service-level agreements.

What we're looking for

• Medi-Cal Dental Program experience needed. Claim/TAR processing preferred. Knowledge of Medi-Cal Dental policies, TARs/claims, eligibility, etc. A minimum of 1-2 years of related work experience.
• Dental x-ray license preferred. Must be able to fluently read dental radiographs. Graduation from an accredited dental assistant school or dental office experience preferred.
• Strong organizational, analytical, and critical thinking skills are essential. Exceptional attention to detail. Excellent customer service skills; fluency in communicating dental terminology.

• Ability to maintain confidentiality, follow up on commitments on a timely basis, and adhere to strict deadlines. Strong team player a must.
• Exceptional formal writing skills are required. Knowledge and application of English grammar including composition, editing, and proofreading skills. Proficiency in MS Office Skills (Outlook, Word, Excel) and Adobe Acrobat required.

What you should expect in this role

• Must be a resident of the state of California.
• Hybrid work environment 1-2 days a week in the office as needed for face-to-face and client meetings with the remainder of the time remote work. The office is located in the Roseville/Sacramento area.