Description:
Job Summary:
In addition to the responsibilities listed below, this position also reviews, evaluates potential quality outcomes, and resolves complaints, grievances, and appeals by leveraging medical knowledge and maintaining compliance to medical protocols, referral methods, claims submission processes, and regulatory guidelines; examining available medical records and treatment summaries to conduct a clinical review of moderately complex coverage requests based on medical necessity criteria, individual coverage contracts, specific health plans, coding rules, and/or other regulatory standards; documenting the review process including decisions for determination of coverage, questions for the physician, and/or potential denials to the physician review staff, independently;supporting the development and implementation of new criteria or changes in existing criteria; and providing consultation to stakeholders regarding medical necessity criteria, contract terms, interpretation of contract language, and notification of determination outcomes.
Essential Responsibilities:
- Promotes learning in others by proactively providing and/or developing information, resources, advice, and expertise with coworkers and members; builds relationships with cross-functional/external stakeholders and customers. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to others and to managers. Pursues self-development; creates and executes plans to capitalize on strengths and develop weaknesses; leads by influencing others through technical explanations and examples and provides options and recommendations. Adopts new responsibilities; adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support a business outcome.
- Completes work assignments autonomously and supports business-specific projects by applying expertise in subject area and business knowledge to generate creative solutions; encourages team members to adapt to and follow all procedures and policies. Collaborates cross-functionally and/or externally to achieve effective business decisions; provides recommendations and solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Supports the development of work plans to meet business priorities and deadlines; identifies resources to accomplish priorities and deadlines. Identifies, speaks up, and capitalizes on improvement opportunities across teams; uses influence to guide others and engages stakeholders to achieve appropriate solutions.
- Drives member, customer, or employee incident case management by: monitoring and analyzing the case tracking database to identify complex, specialty, or flagged cases across all lines of business that require resolution, as well as reporting trends to management; processing complex, specialty/flagged, or high risk incident cases across all lines of business; and ensuring compliance of own work with internal and external rules and regulations in the performance of case management activities with no review necessary.
- Performs member or employee incident case research by: investigating claims, authorizations, member contracts, and/or customer service interactions across members and customers to make determinations for complex and specialty or flagged incident cases.
- Resolves member or employee incident cases by: making decisions regarding complex or specialty/flagged incident cases through interacting with business leaders and other stakeholders and monitoring the decisions of others; and resolving complex or specialty/flagged cases and implementing case decisions at multiple levels.
- Performs customer service by: providing accurate information to members, customers, employees, or other stakeholders related to complex or specialty/flagged case statuses and outcomes in an appropriate timeframe; and communicating with and diffusing frustrated members, customers, or other stakeholders in complex or specialty/flagged cases involving highly charged, sometimes emotional situations.
- Performs case documentation by: maintaining confidentiality of member, customer, or employee information throughout numerous documentation activities for complex or specialty/flagged cases; and documenting complex or specialty/flagged cases in accordance with all internal and external requirements.
Minimum Qualifications:
- Minimum four (4) years of experience in an inpatient setting, clinic, and/or skilled nursing department or a directly health-related field.
- Minimum two (2) years of experience in customer service or a directly related field.
- Minimum one (1) year of experience in a leadership role with or without direct reports.
- Bachelors degree in Business Administration, Economics, Health Care Administration, Health Services, Communications, or related field AND minimum four (4) years of experience in health care, health insurance, sales and marketing, or a directly related field OR Minimum seven (7) years of experience in health care, health insurance, sales and marketing, or a directly related field.
- Registered Nurse License (California) required at hire
- Basic Life Support required at hire
Additional Requirements:
- Knowledge, Skills, and Abilities (KSAs): Clinical Risk Assessment; Health Records; Quality Assurance and Effectiveness; Nursing Principles; Information Gathering; Negotiation; Incident Management; Health Care Compliance; Maintain Files and Records; Data Entry; Acts with Compassion; Interpersonal Skills; Managing Diverse Relationships; Relationship Building; Stakeholder Management; Incident Escalation; Managing Complexity; Time Management; Service Focus; Adaptability; Stress Tolerance; Member Service; Patient Safety; Microsoft Office; Presentation Skills; Incident & Complaint Processes; Business Process Improvement; Trend Analysis; Conflict Resolution
Preferred Qualifications:
