HFHP Appeal

POSITION SUMMARY:

To be fully engaged in providing Uncompromised Safety, Superior Quality, Memorable Patient/Customer Experiences, and Financial Stewardship by resolving member complaints in a timely, professional and compliant manner. Success in this position will be based on the individual's ability to effectively research, document, analyze and resolve complaints according to complex and strict rules, while identifying and communicating issues appropriately.

PRIMARY ACCOUNTABILITIES:

Quality/No Harm:

* Maintaining an understanding of laws, regulations, standards and procedures that guide complaint handling, and resolving complaints in compliance with applicable rules related to procedures and timeframes with them.
* Correctly identifying and interpreting medical, contractual or legal issues related to complaints and communicating them to the appropriate decision-makers.
* Preparing thorough and well-documented case files for internal reviewers, including physician review for medical necessity.

Customer Experience:

* Composing professional, legally-sound and customer-friendly correspondence related to member complaints.
* Collaborating effectively with other Health First Health Plans departments to resolve member complaints.
* Maintaining confidentiality at all times, following departmental and organizational confidentiality guidelines.
* Presenting a professional image to the public.

Stewardship:

* Elevating issues to senior management as necessary to minimize financial risks.
* Reporting trends to help reduce medical or pharmacy costs.

QUALIFICATIONS REQUIRED:

* High School education or equivalent; some college preferred.
* Minimum one (1) year of experience with healthcare business office or health plan.
* Advanced knowledge of prescription drug coverage concepts.
* Advanced knowledge of health care financing and health care delivery.
* Advanced knowledge of Medicare eligibility, coverage and payment provisions.
* Advanced knowledge of commercial insurance provisions.
* Experience working collaboratively with others to achieve goals.
* Consistent demonstration of professional behavior and commitment to quality.
* Demonstrated ability to communicate professionally.

PHYSICAL DEMANDS:

* Maintains a high level of motivation, initiative and accountability.
* Staying organized and effectively prioritizing work and managing time.
* Handling multiple tasks, often within limited time frames.
* Work effectively in a fast-paced and often stressful environment.
* Handling conflict in a productive manner.
* Work effectively with all levels of employees and management.
* Sitting and viewing a computer screen for several hours at a time.

MENTAL DEMANDS:

* Ability to interact with the public in person and telephonically in a positive and professional manner.
* Ability to work and maintain composure in a stressful environment.
* Ability to analyze various situations and provide solutions where appropriate.
* Ability to handle multiple projects simultaneously.
* Ability to work flexible hours as required from time to time in sales environment.

COMPETENCY ASSESSMENT/SKILLS CHECKLIST:

* Highly advanced verbal and written communication skills.
* Effective customer service techniques.
* Analytic and creative problem-solving skills.
* Ability to think critically to define issues, identifies risks, and proposes outcomes.
* Ability to research and understand medical, legal and procedural information related to formal complaints.
* Ability to prepare documented case files to support Health Plan decisions.
* Ability to collect and interpret data.
* Intermediate math skills.
* Advanced computer skills.
* Ability to multi-task.