• Job Description

  Req#: 1271611
  Job Summary:
  
  Responsible for handling the review process for grievances, appeals, or denials including investigating, preparing and presenting appropriate materials for review. Resolves member concerns in partnership with internal and external departments while ensuring compliance with regulatory rules and timeframes.within mandated timeframes and compliance.
  
  
  Essential Responsibilities:
  
  
  
  
  • Participates in handling the grievances, appeals/ denials process. Ensures appeals are processed in accordance with regulations, compliance standards and policies and procedures. Meets timeframes for performance while balancing the need to produce high quality work related to complex and sensitive member issues.
  
  
  • Investigates all issues, including collection of appropriate data, preparation and presentation of documents to decision makers. Informs members or their authorized representatives, physicians and other stakeholders of Health Plans determinations.
  
  
  • Collaborates with internal staff, other MS Departments, managers and physicians to seek resolution on issues and cases affecting member while ensuring compliance, documentation and enhancing members experience. Ensures integrity of departmental database by thorough, timely and accurate entry.
  
  
  • Mentors others in preparation for positions of increased responsibility. Participates in departmental meetings, trainings and audits as requested. Answer questions and manages members on existing / open cases.
  
  
  • 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.

• About the company

  Providing high-quality, affordable health care services and improving the health of our members and the communities we serve.

Notice