Description
12-MONTH CONTRACT POSITION
Job Title: Case Manager for Member Services
Location: Pleasanton, CA 94588
Purpose of this Position:
- Participate in managing the organization's complaint and grievance process for Member Services
Main Responsibilities:
- Accountable for investigation of all issues, including collection and documentation of appropriate data
- Communicate with a diverse set of internal and external clientele to achieve excellent results in the
areas of complaint and grievance handling, compliance, documentation and enhancement of the
member experience - Research, resolve and communicate complaints and grievances filed by members and communicate Health Plan's decisions appropriately back to member or their authorized representatives
- Ensure that complaints and grievances are processed in accordance with regulations, compliance standards and policies and procedures
- Ensure integrity of departmental database by thorough, timely and accurate entry, consistent with regulatory protocols and effectively manage case resolution inbox everyday
Educational Requirement:
- High school diploma or GED required
- Some college preferred
Experience Required (Must Have):
- Manager is looking for or prefers any of the following backgrounds: Coding, Billing, Pharmaceutical, Customer Service and Legal Background in Healthcare or Insurance
- 2 years' experience in a service related industry, call center experience preferred
- 2 years' experience in a complex health care environment preferred
- 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
- Proven ability to deal with difficult customer situations on the phone while under pressure
- Proven skills at defining and researching problems
- Extensive working knowledge of computers to include Windows-based software applications, MS Word, etc.
- Competent working knowledge of Health Plan benefits plan/contracts/systems strongly preferred
- Candidates with journalism or strong writing background would be considered
- Health care experience preferred
Additional Skills Required (Must Have):
- Excellent interpersonal, verbal, and written communication skills
- Work with peers in self-managed teams
- Prioritize work and ensure all compliance elements are met
- Demonstrated conflict resolution and mediation skills
- Use sound judgment and 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, advocates
- 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
- Superior organizational skills
Hours:
8 am - 5 pm, Monday - Friday
All candidates will need to complete a case study/writing test as part of the application process.
Test will be emailed to you.