Case Manager

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Job description

Major Responsibilities/Essential Functions:

-Participate in managing the organization s complaint and grievance process.

-Accountable for investigation of all issues, including collection and documentation of appropriate data.

-Identify and address specialty / flagged cases and follow appropriate processes for different types of cases

-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. Partner with and outreach to internal staff, other MS Departments, managers and physicians to resolve issues as quickly as possible.

-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.

-Meet timeframes for performance while balancing the need to produce high quality work related to complex and sensitive member issues.

-Ensure integrity of departmental database by thorough, timely and accurate entry, consistent with regulatory protocols and effectively manage case resolution inbox everyday

-Participate in departmental meetings, trainings and audits as requested.

-Answer questions and manage members on existing / open cases Escalate issues to management as appropriate to maintain compliance.

Required Skills:

-Experience responding to member benefit, or billing inquiries; responding to Case Resolution quality issues or complaints.

- Demonstrated experience w/ multiple computer applications

- Previous experience working w/ all levels of management/providers

- Candidate must be able to focus on quality and push to resolve issues.

-Must have very strong verbal and written skills.

- Must have proven sills at defining and researching problems.

Minimum Work Experience and Qualifications:

-Experience in a service related industry, call center experience preferred. 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.

-Must be able to work in a Labor/Management Partnership environment.

Experience and Qualifications:

-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 preferred.

-Competent working knowledge of Client Health Plan benefits plan/contracts/systems strongly preferred.

Educational requirement - high school diploma or GED required. Some college preferred.

• Only those lawfully authorized to work in the designated country associated with the position will be considered.

• Please note that all Position start dates and duration are estimates and may be reduced or lengthened based upon a client's business needs and requirements.

Benefits:

For information and details on employment benefits offered with this position, please visit here . Should you have any questions/concerns, please contact our HR Department via our secure website .

California Pay Equity:

For information and details on pay equity laws in California, please visit the State of California Department of Industrial Relations' website here .

Rose International is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender (expression or identity), national origin, arrest and conviction records, disability, veteran status or any other characteristic protected by law. Positions located in San Francisco and Los Angeles, California will be administered in accordance with their respective Fair Chance Ordinances.

If you need assistance in completing this application, or during any phase of the application, interview, hiring, or employment process, whether due to a disability or otherwise, please contact our HR Department .

Rose International has an official agreement (ID ), effective June 30, 2008, with the U.S. Department of Homeland Security, U.S. Citizenship and Immigration Services, Employment Verification Program (E-Verify). (Posting required by OCGA 13/10-91.).

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