Description
Responsible for the investigation, presentation & resolution of expedited member case appeals (72 hour turn around) & Federal & State mandated external independent medical review. Responsible for documentation to terminate members for cause from Health Plan.
Essential Functions:
Serves as Case Manager in managing the organization's closure of Expedited Appeals & processing External Independent Medical Review cases, including
Investigates all appeals, including collection of appropriate documentation
Participates in the Expedited rounds w/Nurse Case Managers & Medical Director
Responds to members, their physicians, & authorized representatives regarding the Health Plan's determination
Prepares appeals for external independent medical review & other state & federal government review
Coordinates w/medical center HP/H & PMG leaders member's care when external independent medical reviewer overturns the Plan's determination
Prepares all cases in accordance w/regulations, compliance standards, & policies & procedures
Partners w/other health plan departments in handling complex issues, politically sensitive issues including documentation, file maintenance, negotiation, resolution, & response
Mentors & serves as consultant to area health plan staff, & other local & divisional entities requiring expertise & advice regarding meeting regulatory requirements or problem solving member grievances
Serves as a case manager in the investigation, preparation & presentation of Health Plan's member termination for cause
Represents Health Plan in Administrative Law Judge cases
Participates in departmental meetings, training's, & unit self audits as requested
Qualifications
Basic Qualifications:
Minimum 3 years of progressively responsible HMO experience or comparable experience
Bachelor's degree or equivalent experience (5+ years) in Business Administration, Economics, Health Care Administration, Health Services, or other related field
Master's degree preferred
Strong knowledge of Expedited Appeals Process & External Independent Medical Review Regulations required
Strong working knowledge of federal & state laws & regulations related to health care & managed care organizations
Excellent interpersonal, verbal, & written communication skills
Conflict resolution & mediation skills w/ability to secure action from persons outside their supervision
Ability to work w/peers in self managed teams to meet deadlines
Ability to use sound judgment & to handle potentially charged issues independently but w/the knowledge
Ability to escalate & ask for help when needed
Ability to multitask & manage time in order to perform well on long-term projects while being flexible enough to assimilate short term projects on an ongoing basis
May (or will) require some (or extensive) travel to the Service Areas &/or Regional offices across the Division
Personal transportation required for local Service Area travel
Must be able to work weekends & holidays
Must be able to work in a Labor/Management Partnership environment