Senior Case Manager

Description: Job Summary:

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 Responsibilities:

Participate in managing the organizations 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 Plans 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. Basic Qualifications:
Experience

• Minimum three (3) years of experience in a service related industry.

Education

• Bachelors 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 members 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 short-term 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:

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

Primary Location: California,Corona,Corona Member Service Call Center
Scheduled Weekly Hours: 40
Shift: Day
Workdays: Mon - Fri
Working Hours Start: 08:00 AM
Working Hours End: 05:00 PM
Job Schedule: Full-time
Job Type: Standard
Worker Location: Remote
Employee Status: Regular
Employee Group/Union Affiliation: NUE-SCAL-01|NUE|Non Union Employee
Job Level: Individual Contributor
Department: Empire Corporate Plaza - Membership Svc Cntr - 0808
Pay Range: $65100 - $84150 / hour The ranges posted above reflect the location in the job posting. The salary range may vary if you reside in a different location or state than the location posted.
Travel: No
Remote: Work location is the remote workplace (from home) within KP authorized states. Worker location must align with Kaiser Permanente's Authorized States policy. At Kaiser Permanente, equity, inclusion and diversity are inextricably linked to our mission, and we aim to make it a part of everything we do. We know that having a diverse and inclusive workforce makes Kaiser Permanente a better place to receive health care, a more supportive partner in our communities we serve, and a more fulfilling place to work. Working at Kaiser Permanente means that you agree to and abide by our commitment to equity and our expectation that we all work together to create an inclusive work environment focused on a sense of belonging and wellbeing.

Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status. Submit Interest

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