Member Services Grievance and Appeals Consultant

We’ve been there for you in the past, providing health care for more than 60 years. We’re here for you today and in days to come, with our ongoing commitment to quality. And we share this tradition and commitment by reaching out to your community, and promoting health and wellness for all.

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, Kaiser Permanente 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. * Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees. **Additional information:** * There are a total of thirty (30) statewide positions available. * Location is flexible: Rancho Cucamonga (SCAL); or Pleasanton or Roseville (NCAL). * If interested in SCAL position, please submit to Job Number 298251. * If interested in both regions, please submit to both NCAL and SCAL postings. * Work days and hours may vary throughout the week on a rotational basis, schedule to include weekends. * These positions may be eligible for telecommuting with a signed agreement between employee and manager.

**Basic Qualifications:** * Minimum three (3) years of HMO experience or comparable experience. * 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. * High School Diploma or General Education Development (GED) required. **Additional Requirements:** * Strong knowledge of Expedited Appeals Process and External Independent Medical Review Regulations required. * 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. * Strong working knowledge of federal and state laws and regulations related to health care and managed care organizations. * May (or will) require some (or extensive) travel to the Service Areas and/or Regional offices across the Division. * Personal transportation required for local Service Area travel. * Must be able to work weekends and holidays. * Must be able to work in a Labor/Management Partnership environment. * Master's degree preferred.