We have a 1 year contract opportunity for a Case Manager in Pleasanton, CA. This position will require 1-2 weeks of onsite training and then will be fully remote. Candidates must live within commuting distance to Pleasanton for equipment pickup.
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.
- 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 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 KP Health Plan benefits plan/contracts/systems strongly preferred.
- High school diploma or GED required.
- Some college preferred.
location: Pleasanton, California
job type: Contract
salary: $25 - 28 per hour
work hours: 8am to 5pm
education: High School
responsibilities:
- 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.
qualifications:
- Experience level: Experienced
- Education: High School
skills:
Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.
At Randstad Digital, we welcome people of all abilities and want to ensure that our hiring and interview process meets the needs of all applicants. If you require a reasonable accommodation to make your application or interview experience a great one, please contact HRsupport@randstadusa.com.
Pay offered to a successful candidate will be based on several factors including the candidate's education, work experience, work location, specific job duties, certifications, etc. In addition, Randstad Digital offers a comprehensive benefits package, including health, an incentive and recognition program, and 401K contribution (all benefits are based on eligibility).
This posting is open for thirty (30) days.
Qualified applicants in San Francisco with criminal histories will be considered for employment in accordance with the San Francisco Fair Chance Ordinance.
Qualified applicants in the unincorporated areas of Los Angeles County with criminal histories will be considered for employment in accordance with the Los Angeles County's Fair Chance Ordinance for Employers.
We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance.
