MCRC Senior Consultant, NCAL (Remote)
Primary Location Pleasanton, California
Worker Location Remote
Job Number 1308537 Date posted 10/17/2024
Navigating the Hiring Process
We're here to support you!
Having trouble with your account or have questions on the hiring process?
Please visit the FAQ page on our website for assistance.
Need help with your computer and browser settings?
Please visit the Technical Information page for assistance or reach out to the web manager at kp-hires@kp.org.
Do you need a reasonable accommodation due to a disability?
A reasonable accommodation is any modification or adjustment that enables you to fully participate in completing the following:
- Online Submissions
- Pre-Hire Assessments
- Interview Process
Please submit your accommodation request and an HR Representative will contact you.
Description:
Essential Responsibilities:
Job Summary:
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 Responsibilities:
- 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 units 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 patients immediate needs within to meet required timeframes. Responds to members, their physicians, and authorized representatives regarding the Health Plans 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.
Secondary Functions:
- Mon - Fri with alternating weekends.
Basic Qualifications:
Experience
- Minimum three (3) years of HMO experience or comparable experience.
Education
- Bachelors 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.
License, Certification, Registration
- N/A
Additional Requirements:
- Strong knowledge of Medicare Part D regulations, 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.
- Proven excellent customer service and service recovery 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.
Preferred Qualifications:
- Masters degree preferred.
Primary Location: California,Pleasanton,Pleasanton Tech Cntr Building F
Scheduled Weekly Hours: 40
Shift: Day
Workdays: Mon, Tue, Wed, Thu, Fri; With alternating weekends
Working Hours Start: 08:00 AM
Working Hours End: 05:00 PM
Job Schedule: Full-time
Job Type: Standard
Worker Location: Remote
Employee Status: Regular
Employee Group/Union Affiliation: NUE-NCAL-09|NUE|Non Union Employee
Job Level: Individual Contributor
Department: Oakland Reg - 2101 Webster - Grp Rltn-Sales&Mrktng Integrtn - 0208
Pay Range: $78800 - $101970 / hour
The ranges posted above reflect the location in the job posting. The salary range may vary if you reside in a different location or state than the location posted.
Travel: No
Remote: Work location is the remote workplace (from home) within KP authorized states.
Worker location must align with Kaiser Permanente's Authorized States policy.
At Kaiser Permanente, equity, inclusion and diversity are inextricably linked to our mission, and we aim to make it a part of everything we do. We know that having a diverse and inclusive workforce makes Kaiser Permanente a better place to receive health care, a more supportive partner in our communities we serve, and a more fulfilling place to work. Working at Kaiser Permanente means that you agree to and abide by our commitment to equity and our expectation that we all work together to create an inclusive work environment focused on a sense of belonging and wellbeing.
Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status. Submit Interest
Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status. Submit Interest
