Case Manager Pleasanton, CA
Position located within Correspondence center, reporting to Correspondence Center Team Lead or to Correspondence Center Assistant Director. Responsible for handling member concerns through research and communication with involved departments / member. Partner with internal and external departments and staff to achieve resolution for member concerns. Manage database for cases. Responsible for timely case resolution and maintaining compliance.
- Participate in managing the organization's complaint and grievance process. Accountable for investigation of all issues, including collection and documentation of appropriate data. Identify and address specialty / flagged cases and follow appropriate processes for different types of cases. Communicate 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.
- Partner with and outreach to internal staff, other MS Departments, managers and physicians to resolve issues as quickly as quickly as possible. Research, resolve and communicate complaints and grievances filed by members and communicate Health Plan's decisions appropriately back to member or their authorized representatives
- Ensure that complaints and grievances are processed in accordance with regulations, compliance standards and policies and procedures. Meet timeframes for performance while balancing the need to produce high quality work related to complex and sensitive member issues.
- Ensure integrity of departmental database by thorough, timely and accurate entry, consistent with regulatory protocols and effectively manage case resolution inbox everyday.
- Answer questions and manage members on existing / open cases. Escalate issues to management as appropriate to maintain compliance
- Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees.
- Minimum four (4) years of customer service experienceOR minimumfour (4) years working in a complex health care environment.
- High School Diploma or General Education Development (GED) required.
License, Certification, Registration
- Strong working knowledge of federal and state regulations, laws and accreditation standards related to health care and managed care organizations.
- Competent working knowledge of KP Health Plan benefits plan/contracts/systems.
- Excellent interpersonal, verbal and written communication skills.
- Ability to work with peers in self-managed teams.
- Ability to prioritize work and ensure all compliance elements are met.
- Ability to use sound judgment and 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 short term projects on an ongoing basis.
- Demonstrated conflict resolution and mediation skills with ability to secure action from multiple stakeholders.
- Demonstrated ability to work in a time-sensitive environment involving patients, family members and advocates.
- 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.
- Minimum one (1) year of experience handling complaints and issue resolutions, and interpreting health plan coverage and contractual agreements.
- Bachelor's degree preferred.
Primary Location: California,Pleasanton,Pleasanton Tech Cntr Building F 5810 Owens Dr.
Scheduled Hours (1-40): 40
Working Days: Mon-Fri
Job Type: Standard
Employee Status: Regular
Employee Group: Non-Union, Non-Exempt
Job Level: Entry Level
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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