Member Relations Consultant - Contract to Hire

Company Name:
Start date: October 2014
Duration: Contract to Hire
Minimum salary: 25.00 USD
Maximum salary: 25.00 USD
Salary period: Hourly
Additional classifications: Medical/Hospital, Customer Service
Member Relations Sr Consultant
Potential to Convert to an FTE
Candidates will be participate in managing the organization's expedited complaint and grievance process for Member Services.
Responsible for the investigation, presentation and resolution of expedited member case appeals (24-72 hour turn around) and Federal and State mandated external independent medical review.
Responsible for documentation to terminate members for cause from Health Plan. Responsible for representing Health Plan in Administrative Law Judge cases.
Serves as Case Manager in managing the organization's closure of Expedited Appeals and processing External Independent Medical Review cases, including: investigates all appeals, including collection of appropriate documentation, participates in the Expedited rounds with Department Managers, Clinical Consultants and Physician reviewers, responds to members, their physicians, and authorized representatives regarding the Health Plan's determination.
Prepares appeals for external independent medical review and other state and federal government review.
Coordinates with medical center HP/H and PMG leaders member's care when external independent medical reviewer overturns the Plan's determination.
Prepares all cases in accordance with regulations, compliance standards, and policies and procedures.
Partners with other health plan departments, Hospital staff, and PMGs in handling complex issues, politically sensitive issues including documentation, file maintenance, negotiation, resolution and response.
Mentors and serves as consultant to area health plan staff, and other local and divisional entities requiring expertise and advice regarding meeting regulatory requirements or problem solving member grievances.
Serves as a case manager in the investigation, preparation and presentation of Health Plan's member termination for cause.
Represents Health Plan in Administrative Law Judge cases.
Participates in departmental meetings, training's, and unit self audits as requested.
Candidates must have dynamic, strong communication skills both interpersonal and written.
Candidate must have very strong ability to communicate verbally and in writing.
Proven Customer Service Skills while working under pressure.
Ability to multitask and superior organizational skills are a must.
Manager looking for or prefers any of the following backgrounds: Coding, Billing, Pharmaceutical, Customer Service & Legal Background in Healthcare or Insurance Experience.
Also candidates with journalism or strong writing background would be considered. Candidates must have proven ability to deal with difficult customers situations on the phone.
Must have proven skills at defining and researching problems.
Minimum three (3) years of HMO experience.
Candidate must also have Healthcare experience or comparable experience in a Customer Service/Enrollment/Benefits role or similar role.
Bachelor's degree in business administration, economics, health care administration, health services, or other related field is preferred
Four (4) years of experience in a directly related field with High School Diploma or General Education Development (GED) REQUIRED
Strong knowledge of Expedited Appeals Process and External Independent Medical Review Regulations required.
Strong working knowledge of federal and state laws and regulations related to health care and managed care organizations.
Excellent interpersonal, verbal and written communication skills.
Ability to work with peers in self managed teams to meet deadlines.
Demonstrated conflict resolution and mediation skills with ability to secure action from persons outside their supervision.
Ability to use sound judgment and to handle potentially charged 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.
Strong working knowledge of federal and state laws and regulations related to health care and managed care organizations.
Personal transportation required for local Service Area travel.
Must be able to work weekends and holidays.
Must be able to work in a Labor/Management Partnership

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