Decrease plan exposure to bad faith or breach of contract law suits, regulatory sanctions, employer-group penalties and adverse media by effectively resolving complaints, grievances and appeals region-wide in compliance with federal/state/contractual laws/regulations, plan policy and legal principles; enhance employer-group retention through resolution of complex or sensitive complaints, advise Care Delivery managers working with difficult customers to ensure contractual and legal requirements are met, promote member retention and reduce plan liability.
Essential Functions:
- Adjudicate customer grievances, appeals and exception requests; assess plan obligation and potential risk; comply with federal/state and contractual laws/regulations; negotiate settlements; develop and submit appeal summaries to the Centers for Medicare & Medicaid Services (CMS) for Health Dispute Resolution, Federal Employee Health Benefit (FEHB) appeals to Office of Personnel Management (OPM); provide contract interpretations; research and develop oral and written case summaries; provide written and oral testimony to support HP Counsel and Contract Administration in response to Administrative Law Judge/Oregon Health Plan hearings, small claims courts, law suits and arbitrations
- Resolve complicated or sensitive employer-initiated complaints; negotiate satisfactory resolutions with Care Delivery administrators and Health Plan departments
- Provide complaint information for trending and specific employer-group interventions
- Respond to formal inquiries from public figures, Insurance Commissioners, federal/state/public agencies to establish and maintain positive relations and comply with state/federal regulations
- Ensure plan consistency in organizational responses and represent senior managers by developing written responses to inquiries or complaints directed to Health Plan and regional senior leaders
- Analyze research, initiate action and provide written response within required timelines
- Inform key managers of sensitive inquiries and recommend options/solutions
- Advise and direct interventions of Care Delivery managers and physicians when dealing with difficult, sensitive and high risk member/patient or group situations to promote member and group satisfaction and retention
- Reduce potential plan liability by ensuring compliance with explicit and implicit contractual obligations and federal/state government laws/regulations
- Support plan and affiliated providers/managers/staff when dealing with members who demonstrate inappropriate, abusive, intimidating or physically violent behaviors; issue warning letters, develop behavioral contracts or case management protocols or terminate member's membership according to Health Plan protocol
- Perform other duties as requested
Qualifications:
Basic Qualifications:
- 2 years of experience working directly with customers in a service, marketing, risk management, or health care related role disseminating complex information orally and in writing to customers, staff and clinicians
- 2 years of experience negotiating settlements, resolution of disputes, or negotiating process/policy changes with customers and higher level managers
- 1 year of experience in position using medical terminology to determine what treatment or level of care was provided or to interpret information for further dissemination or decision-making
- High School diploma or GED
- Thorough knowledge of medical terminology
- Basic knowledge of health care benefits and services
- Knowledge of clinical services, policies and procedures
- Ability to assimilate and apply complex and diverse state/federal regulations, accreditation requirements, and similar material
- Demonstrated experience providing effective, positively received presentations to groups
- Demonstrated ability to use word processor or computer terminal
- Excellent oral communication skills; demonstrated ability to negotiate in highly charged emotional situations, defuse anger and resolve conflicts both in person and over the telephone by utilizing a variety of mediation, conflict resolution and negotiation methods
- Excellent writing skills; demonstrated ability to summarize complex and sensitive information, and write reports/memos/letters in a clear, concise, non-judgmental, non-threatening and effective manner
- Excellent judgment, analytical and problem-solving skills; demonstrated ability to interpret complex medical, contractual or legal material, identify important issues, assess completeness or adequacy of information, make independent decisions under a frame work of general policy and develop effective recommendations
- Excellent time management/prioritization skills; demonstrated ability to handle multiple tasks, with shifting priorities, successfully meeting deadlines with a high volume of work
Preferred Qualifications:
- Minimum of 2 years of plan experience; working knowledge of plan service agreements, operational structure/policies/procedures
- Intermediate/competent knowledge of internal computer systems including Lotus Notes/HealthConnect/Common Membership/Diamond/Axium/MS Office/Resolute
- Basic knowledge of federal and state regulations pertaining to adverse benefit determinations, grievances and appeals and provision of care/services
- Basic knowledge of legal concepts; e.g., contract law, malpractice
Salary Range:
$66,740 - $91,460
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.