ERU Sr. Consultant: Responsible for the investigation, presentation & resolution of expedited member case appeals (72 hour turn around). PDU Sr. Consultant: Responsible for the investigation, presentation & resolution of expedited & standard medicare Part D coverage determinations & redeterminations (24 to 72 hour turn around), & Part D grievances. CCU Sr. Consultant: Responsible for the investigation, presentation & resolution of member complaints & grievances that meet the MCRC complex case unit (CCU) criteria.

Essential Functions:

- Serves as Case Mrg in managing the organization's closure of Expedited Appeals, Part D coverage determinations & redeterminations, & MCRC grievances that meet the Complex Case Unit (CCU) criteria.
- These include the following:
- Investigates all complaints, grievances & appeals, including collection of appropriate documentation.
- Participates in the Expedited rounds w/ Nurse Case Mrgs & Medical Director (ERU).
- Participates in the Part D benefit committee.
- In conjunction w/ TM, participates in Part D coverage decisions & facilitates MD review of medical necessity requests (PDU).
- Participates in CCU weekly rounds & partners w/ clinical consultants.
- In conjunction w/ TL/TM, participates in benefit decisions, facilitates MD review of medical necessity requests, & facilitates the appropriate level of internal review based upon case merits & organizational risk.
- Is involved & partners w/ medical center & regional leadership to facilitate the appropriate review, resolution & service recovery for high profile, highly sensitive cases.
- Makes initial & follow up contact w/ patient/member throughout the case & ensure patient's immediate needs are met timely (appointments, facilitating care) (CCU).
- Responds to members, their physicians, & authorized representatives regarding the Health Plan's determination.
- Prepares all cases in accordance w/ regulations, compliance standards, & policies & procedures.
- Partners w/ other health plan Depts, KP Hospital staff, & PMGs 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.
- Represents Health Plan in Administrative Law Judge cases.
- Participates in departmental meetings, trainings, & unit self-audits as requested.
- KP conducts compensation reviews of positions on a routine basis. At any time, KP reserves the right to reevaluate & 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.
- Consistently supports compliance & the Principles of Responsibility (KP's code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting w/ ethics & integrity, reporting non-compliance, & adhering to applicable Federal & State laws & regulations, accreditation & licensure requirements, & KP policies & procedures.
- In addition to defined technical requirements, accountable for consistently demonstrating service behaviors & principles defined by the KP Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives.
- Also accountable for consistently demonstrating the knowledge, skills, abilities, & behaviors necessary to provide superior & culturally sensitive service to each other, to our members, & to purchasers, contracted providers & vendors.