Job Summary:Responsible for handling grievances and appeals review process through investigation, preparation, effectuation, and member resolution. Partner with internal and external departments, Medical Group and staff to achieve resolution for member concerns. Positively impacts member experience by providing timely, appropriately sensitive, professional, and thorough responses to grievances or appeals. This includes written and verbal communication with members/customers, research, documentation and resolution in collaboration with health care providers, Care Delivery and Health Plan managers. Responsible for timely case resolution and compliance with federal and state regulations, laws and accreditation standards. Contributes to the departments success through team building, conflict resolution, group interaction.Essential Responsibilities:
Manages grievance cases by reviewing and discerning relevant issues and coordinating research with appropriate stakeholders. Communicate and collaborate with a diverse set of internal and external clientele to achieve excellent results in the areas of complaint and grievance handling, compliance, documentation and enhancement of the member experience. Upon compilation of pertinent information, develops appropriate verbal and/or written customer responses. Provides clear and concise written case summaries which are made available for both internal audits and audits by state and federal regulatory agencies. Communicates with and diffuses angry customers in highly charged, sometimes emotional situations. Ensure integrity of departmental database by thorough, timely and accurate entry, consistent with regulatory protocols and effectively manage case resolution inventory every day. Answer questions and manage members on existing / open cases. Escalate issues to management as appropriate to maintain compliance.
Makes decisions on appropriate case types using their own critical thinking, taking into account policy and guidelines. Provides information for trending and specific complaint resolution interventions.
Develops & maintains relationships w/ key individuals in order to facilitate research & resolution of complaints and appeals to ensure timeliness of resolution.
Implements any corrective actions necessary to address internal and external audit findings.
Basic Qualifications:
Experience
Minimum two (2) years of customer service experience to include one or more of the following: working directly with customers in a health care related role disseminating complex information orally and in writing to customers, staff and clinicians, or service, marketing, risk management, or
Minimum two (2) years working in a complex health care environment required.
Education
High School Diploma or General Education Development (GED) required.
License, Certification, Registration
N/A
Additional Requirements:
Knowledge of regulations and / or accreditation standards relating to complaints and grievances.
Exceptional verbal and written communication skills, as well as relationship management skills including experience communicating with executives.
Exceptional customer service orientation.
Demonstrated experience with multiple computer applications; MS Word, MS Excel, MS PowerPoint.
Excellent organizational and time management skills.
Proven analytical skills and the ability to problem solve.
Superior interpersonal skills, teamwork, emotional intelligence and communication skills.
Demonstrated ability to identify important issues, involve appropriate individuals and develop appropriate recommendations and action plans from multi-disciplinary perspectives.
Proficient in team building and conflict resolution.
Knowledge of regional market products and benefit packages and issues that impact the regions.
Must be able to work in Labor/Management Partnership environment.
Preferred Qualifications:
Bachelors degree in education, business, health care administration, communications, or a related field preferred.
One (1) year experience in a position using medical terminology to determine what treatment or level of care was provided or to interpret information for further dissemination.
One (1) years of experience negotiating settlements, resolution of disputes, or negotiating process/policy changes with customers and higher level managers.
Experience within KP in direct member contact position.
Experience negotiating problem resolution with higher level managers.
COMPANY: KAISERTITLE: Grievances & Appeals ConsultantLOCATION: Portland, OregonREQNUMBER: 1277975External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.