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Senior Case Manager Rancho Cucamonga, CA



Description

Position located within the Correspondence center, reporting to the Correspondence Center Team Lead or Correspondence Center Assistant Director. Responsible for handling grievances and appeals review process through investigation, preparation, effectuation, and presentation of appropriate materials for review. Partner with internal and external departments, Medical Group and staff to achieve resolution for member concerns. Manages database for cases. Responsible for timely case resolution and compliance with federal and state regulations, laws and accreditation standards.

Essential Functions:
- Participate in managing the organization's Grievance, Appeal and External Review process.
- Accountable for investigation and response of all issues, including collection of appropriate data, preparation and presentation of documents to decision makers.
- Responsible for responding to members or their authorized representatives, physicians and other stakeholders regarding the Health Plan's determination within regulatory timeframes while meeting quality and customer focused standards.
- Communicate with a diverse set of internal and external clientele to achieve excellent results in the area of case handling, compliance, documentation and enhancement of the member experience.
- Partner with and outreach to internal staff, other MS Departments, managers and physicians to resolve issues as quickly as possible.
- Ensures appeals are processed and effectuated in accordance with regulations, compliance standards and policies and procedures.
- Meets timeframes for performance while balancing the need to produce high quality work related to complex and sensitive member issues.
- Ensures integrity of departmental database by thorough, timely and accurate entry.
- Mentors others in preparation for positions of increased responsibility.
- Participates in departmental meetings, trainings and audits as requested Answer questions from members/advocates on existing/open cases Escalates issues to management as appropriate.
- Ensures regulatory compliance with work product.


Qualifications:

Basic Qualifications:
Experience
- Minimum three (3) years of experience in a service related industry.
Education
- Bachelor's degree required, OR four (4) years of experience in a directly related field.
- High School Diploma or General Education Development (GED) required.
License, Certification, Registration
- N/A

Additional Requirements:
- Excellent interpersonal, verbal and written communication skills.
- Demonstrated ability to compose high quality, compliant, grammatically correct, detailed written communication.
- Ability to identify all issues of a member's concern, gather, assess and present information.
- Ability to prioritize work and ensure all compliance elements are met.
- Demonstrated conflict resolution and mediation skills with ability to secure action from multiple stakeholders.
- Ability to use sound judgment and critical thinking to handle complex issues independently, but with the knowledge and ability to escalate and ask for help when needed.
- Ability to multitask and manage time in order to perform well on long term projects while being flexible enough to assimilate shortterm projects on an ongoing basis.
- Ability to work collaboratively with peers in self-managed teams.
- Demonstrated ability to work in a time-sensitive environment.
- Ensures regulatory compliance with work product.
- Extensive working knowledge of personal computers to include Windows based software applications, MS Word, etc.
- Must be able to work in a Labor/Management Partnership environment.

Preferred Qualifications:
- Three (3) years of experience in a complex health care environment.
- Knowledge of member grievance and appeals processing preferred.
- Competent working knowledge of Kaiser Permanente Health Plan benefit plan/contracts/systems strongly preferred.
- Strong working knowledge of federal and state regulations, laws and accreditation standards related to health care and managed care organizations.


Primary Location: California,Rancho Cucamonga,Empire Corporate Plaza 10740 4th St.

Scheduled Hours (1-40): 40

Shift: Day

Working Days: Tue, Wed, Thu, Fri, Sat

Schedule: Full-time

Job Type: Standard

Employee Status: Regular

Employee Group: Non-Union, Non-Exempt

Job Level: Manager with Direct Reports

Job: Customer Services

Public Department Name: Member Services


External 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.

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