Case Manager

1 day ago

Corona, California, United States Randstad Full time
Job Summary

We are seeking a highly skilled Case Manager to join our team in Corona, California. As a Case Manager, you will be responsible for managing the organization's complaint and grievance process, investigating issues, and communicating with internal and external stakeholders to achieve excellent results in complaint and grievance handling, compliance, documentation, and enhancement of the member experience.

Key Responsibilities
  • Participate in managing the organization's complaint and grievance process.
  • Accountable for investigation of all issues, including collection and documentation of appropriate data.
  • Identify and address specialty / flagged cases and follow appropriate processes for different types of cases.
  • Communicate with a diverse set of internal and external clientele to achieve excellent results in the areas of complaint and grievance handling, compliance, documentation, and enhancement of the member experience.
  • Partner with and outreach to internal staff, other MS Departments, managers, and physicians to resolve issues as quickly as possible.
  • Research, resolve, and communicate complaints and grievances filed by members and communicate Health Plan's decisions appropriately back to member or their authorized representatives.
  • Ensure that complaints and grievances are processed in accordance with regulations, compliance standards, and policies and procedures.
  • Meet timeframes for performance while balancing the need to produce high-quality work related to complex and sensitive member issues.
  • Ensure integrity of departmental database by thorough, timely, and accurate entry, consistent with regulatory protocols, and effectively manage case resolution inbox every day.
  • Participate in departmental meetings, trainings, and audits as requested.
  • Answer questions and manage members on existing / open cases. Escalate issues to management as appropriate to maintain compliance.
Requirements
  • Experience in a service-related industry, call center experience preferred.
  • Excellent interpersonal, verbal, and written communication skills.
  • Ability to work with peers in self-managed teams.
  • Ability to prioritize work and ensure all compliance elements are met.
  • Demonstrated conflict resolution and mediation skills with ability to secure action from multiple stakeholders.
  • Ability to use sound judgment and to handle complex issues independently, but with the knowledge and ability to escalate and ask for help when needed.
  • Demonstrated ability to work in a time-sensitive environment involving patients, family members, and advocates.
  • Extensive working knowledge of personal computers to include Windows-based software applications, MS Word, etc.
  • Ability to multitask and manage time in order to perform well on long-term projects while being flexible enough to assimilate short-term projects on an ongoing basis.
  • Must be able to work in a Labor/Management Partnership environment.
Preferred Qualifications
  • Experience in a complex healthcare environment preferred.
  • Strong working knowledge of federal and state regulations, laws, and accreditation standards related to healthcare and managed care organizations.
  • Knowledge of member complaint and grievance processing preferred.
  • Competent working knowledge of KP Health Plan benefits plan/contracts/systems strongly preferred.
Education

High school diploma or GED required. Some college preferred.

Location

Corona, California

Job Type

Contract

Salary

$21 - 24 per hour

Work Hours

8am to 5pm

Education

High School

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