Health Care Case Manager - 6-Month Contract (may Convert) (53049)

HEALTH CARE CASE MANAGER/MEMBER RELATIONS SENIOR CONSULTANT

DURATION: 6-month contract (W2) - possible conversion to FTE

LOCATION: Oakland, CA 94612

JOB NUMBER: 53049

CLIENT: One of the country's largest health care and health plan providers

DEPARTMENT: California Member Services - Expedited Review Unit

PURPOSE OF THE POSITION:

- Candidates will be participating in managing the organization's expedited complaint and grievance process for Member Services

JOB DESCRIPTION:

- 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

DAILY RESPONSIBILITIES/REQUIRED SKILLS:

- 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, trainings, and unit self-audits as requested

QUALIFICATIONS:

- Bachelor's degree in business administration, economics, health care administration, health services, or other related field OR 4 years' experience in a directly related field
- High School Diploma or General Education Development (GED) required
- Minimum 3 years of HMO experience
- 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
- Demonstrated conflict resolution and mediation skills with ability to secure action from persons outside their supervision
- 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
- Proven ability to deal with difficult customers situations on the phone
- Must have proven skills at defining and researching problems
- 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
- Health care experience preferred

MUST BE ABLE TO WORK WEEKENDS AND HOLIDAYS

HEALTH SCREEN REQUIRED AS PART OF ON-BOARDING PROCESS

* AS PART OF THE APPLICATION PROCESS, CANDIDATES WILL NEED TO COMPLETE A WRITING SAMPLE WHICH WILL BE EMAILED TO THEM.*