Grievance and Appeals Case Manager Job in Glendale, California Us

Position located within Correspondence center, reporting to Correspondence Center Team Lead or to Correspondence Center Assistant Director. Responsible for handling member concerns through research communication w/ involved departments / member. Partner w/ internal external departments staff to achieve resolution for member concerns. Manage database for cases. Responsible for timely case resolution maintaining compliance.
Essential Functions:
- Participate in managing the organization's complaint grievance process
- Accountable for investigation of all issues, including collection documentation of appropriate data
- Identify address specialty/ flagged cases follow appropriate processes for different types of cases
- Communicate w/ a diverse set of internal external clientele to achieve excellent results in the areas of complaint grievance handling, compliance, documentation enhancement of the member experience
- Partner w/ outreach to internal staff, other MS Departments, managers, physicians to resolve issues as quickly as possible
- Research, resolve communicate complaints grievances filed by members communicate Health Plan's decisions appropriately back to member or their authorized representatives
- Ensure that complaints grievances are processed in accordance w/ regulations, compliance standards policies procedures
- Meet timeframes for performance while balancing the need to produce high quality work related to complex sensitive member issues
- Ensure integrity of departmental database by thorough, timely, accurate entry, consistent w/ regulatory protocols effectively manage case resolution inbox everyday
- Participate in departmental meetings, trainings, audits as requested
- Answer questions manage members on existing/ open cases
- Escalate issues to management as appropriate to maintain compliance
Qualifications:
Basic Qualifications:
- Two (2) years of experience in a service related industry
- Two (2) years of experience in a complex health care environment, preferred
- Bachelors' degree or equivalent experience
- Excellent interpersonal, verbal and written communication skills
- Ability to work with peers in self-managed teams
- Ability to prioritize work and ensure all compliance elements are met
- 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
- Demonstrated ability to work in a time-sensitive environment involving patients, family members and advocates
- Extensive working knowledge of personal computers to include Windows based software applications, MS Word, etc. (added)
- 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
- Strong working knowledge of federal and state regulations, laws and accreditation standards related to health care and managed care organizations, preferred
- Knowledge of member complaint and grievance processing preferred
- Competent working knowledge of KP Health Plan benefits plan/contracts/systems strongly preferred
- Must be able to work in a Labor/Management Partnership environment

Preferred Qualifications:
- Two (2) years experience in a complex health care environment.
- Strong working knowledge of federal and state regulations, laws and accreditation standards related to health care and managed care organizations.
- Knowledge of member complaint and grievance processing preferred.
- Competent working knowledge of KP Health Plan benefits plan/contracts/systems strongly preferred.