Health Insurance Member Relations Consultant - 4 Months (69536)

HEALTH INSURANCE MEMBER RELATIONS CONSULTANT

CONTRACT: 4 months (W2)

LOCATION: Oakland, CA 94612

JOB NUMBER: 69536

DEPARTMENT: Membership Service Center

HOURS: Must be flexible with overtime, and able to work weekends and holidays

JOB DESCRIPTION:

Responsible for the handling of member complaints and grievances for the resolution of expedited, complex and Medicare Part D cases in accordance with all applicable contract provisions, plan policies, procedures, rules and regulations.

ESSENTIAL FUNCTIONS:

- Manages the resolution of expedited appeals, Part D coverage determinations and redeterminations, as well as complex grievance cases. Prepares all cases in accordance with regulations, compliance standards, and policies and procedures.
- Investigates all complaints, grievances and appeals, including collection of appropriate documentation. Represents Health Plan in Administrative Law Judge cases. Participates in departmental meetings, trainings, and unit self-audits as requested.
- Participates in the expedited rounds with Nurse Case Managers and Medical Director (ERU), Part D coverage decisions and complex case unit's weekly rounds and partners with clinical consultants. Participates in benefit decisions.
- Facilitates physicians' review of medical necessity requests, and appropriate level of internal reviews based upon case merits and organizational risk. Works with medical center and regional leadership to facilitate the appropriate review, resolution and service recovery for high profile, highly sensitive cases.
- Makes initial and follow up contacts with patient/members. Helps facilitates care to meet patient's immediate needs within to meet required timeframes. Responds to members, their physicians, and authorized representatives regarding the Health Plan's determination.
- 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.

REQUIRED EDUCATION, EXPERIENCE, AND SKILLS:

- Bachelor's degree in business administration, economics, health care administration, health services, or other related field OR four (4) years of experience in a directly related field - Master's degree preferred
- Minimum 3 years' HMO experience or comparable experience
- Strong knowledge of Expedited Appeals Process and External Independent Medical Review Regulations
- 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
- Must be able to work in a Labor/Management Partnership environment