Case Manager-Member Services Grievances 6 Month Contract

Case Manager, Member Services Grievance Unit

Description:
-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 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.
-Participate in departmental meetings, trainings and audits as requested.
-Answer questions and manage members on existing/open cases Escalate issues to management as appropriate to maintain compliance.
-Will work varied shifts.

Requirements:
-Two years experience in a service related industry, in a complex health care environment.
-Call center experience preferred.
-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.
-Demonstrated conflict resolution and mediation skills with ability to secure action from multiple stakeholders.
-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.
-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.
-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.
-Must be able to work in a Labor/Management Partnership environment.
-Strong working knowledge of federal and state regulations, laws and accreditation standards related to health care and managed care organizations.
-Knowledge of member complaint and grievance processing preferred.
-Competent working knowledge of Health Plan benefits plan/contracts/systems strongly preferred.
-Strong writing skills, syntax, grammar and spelling competency.
-Editorial experience, previous writing position preferred.
-Strong customer service, phone skills in diffusing member complaints strongly preferred.
-High school diploma or GED required.
-4 year degree in education, journalism, communication or related field preferred.