27 days old

MCRC Senior Consultant

Kaiser Permanente
Pleasanton, CA 94588
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 Functions:
- 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 unit's 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 patient's immediate needs within to meet required timeframes. Responds to members, their physicians, and authorized representatives regarding the Health Plan's 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.


Posted: 2019-11-13 Expires: 2019-12-13

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MCRC Senior Consultant

Kaiser Permanente
Pleasanton, CA 94588

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