Expedited Appeals Case Manager


Streffco Consultants, Inc., is an international technical staffing and systems integration organization. We provide technology and business operations resources on a project, contract, contract-to-hire or direct hire basis.
Title: Member Relations Sr. Consultant
Job ID: 55882
Industry: Healthcare
Location: Oakland, CA
Duration: 6 months (Possible Temp to Hire)
Pay Rate Range: Depends on Experience (W-2 all inclusive rate)

Purpose and Description:
Responsible for the investigation, presentation and resolution of expedited member case appeals (24-72 hour turn around) for Federal and State mandated external independent medical review
Responsible for documentation to terminate members for cause from Health Plan
Responsible for representing Client Health Plan in Administrative Law Judge cases
Candidates will be participate in managing the organization's expedited complaint and grievance process for Member Services
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
Essential Functions:
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, Kaiser Permanente 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
Required
Experience:
High School Diploma or General Education Development (GED) required
Minimum three (3) years of HMO experience. Candidate must also have on experience or comparable experience in a Customer Service/Enrollment/Benefits role or similar role
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
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
Preferred
Experience:
Healthcare experience preferred
Skills to be successful in this role:
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
Please respond by submitting your resume in a Word Document.
(Please include the job title and id# in the subject line)
We will not respond to everyone personally - qualified candidates will be contacted for an interview.

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