Health Plan Appeals Case Manager - 3-Month Contract (51530)

HEALTH PLAN APPEALS CASE MANAGER

DURATION: 3-month contract (W2)

LOCATION: Oakland, CA 94612

JOB NUMBER: 51530

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

JOB DESCRIPTION:

- Responsible for handling the review process for appeals or denials including investigating, preparing and presenting appropriate materials for review
- Resolves member concerns in partnership with internal and external departments while ensuring compliance with regulatory rules and timeframes within mandated timeframes and compliance

ESSENTIAL FUNCTIONS:

- Participates in handling the appeals/denials process
- Ensures appeals are processed in accordance with regulations, compliance standards and policies and procedures
- Meets timeframes for performance while balancing the need to produce high quality

work related to complex and sensitive member issues - Investigates all issues, including collection of appropriate data, preparation and presentation of documents to decision makers
- Informs members or their authorized representatives, physicians and other stakeholders of Health Plan's determinations
- Collaborates with internal staff, other MS Departments, managers and physicians to seek resolution on issues and cases affecting member while ensuring compliance, documentation and enhancing members' experience
- Ensures integrity of departmental database by thorough, timely and accurate entry
- Mentors others in preparation for positions of increased responsibility
- Participates in departmental meetings, trainings and audits as requested
- Answer questions and manages existing/open cases

TOP DAILY RESPONSIBILITIES:

- Coordinating appeals received for hospitals, skilled nursing facility and home health
- Writing detailed notices timely and accurately
- Processing requests for skilled nursing facility denial letters
- Educating regional partners to the appeals process
- Interaction with our customers (nurses, staff, physicians) at local facilities (telephonic, electronic)

REQUIREMENTS (MUST HAVE):

- Bachelors' degree
- Minimum 4 years' experience in a complex HMO or customer service setting
- Basic computer skills (Microsoft Word and basic Excel), working knowledge of computerized/electronic medical record systems (eg, EPIC), use of RightFax
- Knowledge of medical terminology
- Knowledge of member grievance and appeals processing preferred
- Excellent interpersonal, verbal and written communication skills
- Demonstrated ability to compose high quality, detailed written communication
- Ability to identify issues, gather and assess information
- 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
- Ability to multitask, manage time, and prioritize work to ensure all compliance elements are met