Healthcare Claims Case Manager - Min. 3 Month Contract

Healthcare Claims Case Manager

Job Description:

Position located within the Correspondence center, reporting to the Correspondence Center Team Lead or Correspondence Center Assistant Director.

RESPONSIBLE FOR HANDLING GRIEVANCES AND APPEALS REVIEW PROCESS THROUGH INVESTIGATION, PREPARATION, EFFECTUATION, AND PRESENTATION OF APPROPRIATE MATERIALS FOR REVIEW.

PARTNER WITH INTERNAL AND EXTERNAL DEPARTMENTS, MEDICAL GROUP AND STAFF TO ACHIEVE RESOLUTION FOR MEMBER CONCERNS.

MANAGES DATABASE FOR CASES.

Responsible for timely case resolution and compliance with federal and state regulations, laws and accreditation standards.
Participate in managing the organization's Grievance, Appeal and External Review process.
Accountable for investigation and response of all issues, including collection of appropriate data, preparation and presentation of documents to decision makers.
Responsible for responding to members or their authorized representatives, physicians and other stakeholders regarding the Health Plan's determination within regulatory timeframes while meeting quality and customer focused standards.
Communicate with a diverse set of internal and external clientele to achieve excellent results in the area of case 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.
Ensures appeals are processed and effectuated 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.
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 from members/advocates on existing/open cases Escalates issues to management as appropriate.
Ensures regulatory compliance with work product.

Requirements:
-Letter writing background (ie. English degree, literature degrees, publication work history, etc)
-Customer Service background (work experience in a face to face environment or high customer interaction)
-Analytical/Critical thinking - This job is working member problems in a multi-faceted organization.
-Needs to identify root cause, decision maker and can explain to members/stakeholders
-Regulatory knowledge (DMHC, CMS, DHCS, JOC, NCQA, ETC) This job would be close to DMHC regulations
-Self-driven, can manage shifting priorities and has a team attitude
-Strong writing skills, syntax, grammar and spelling competency.
-Strong customer service, phone skills in diffusing member complaints.
-Manager would like them to understand customer service dynamics but have also proven writing skills (English or communications degree, correspondence experience etc.)
-High School diploma or GED required, some college preferred.