Representative

Job Summary :

This position is under review and must follow the guidelines in accordance with the respective collective bargaining agreements and / or NLRB definition of a confidential employee.

This position must be reviewed in partnership with HR Consulting prior to posting. Position(s) located within the local area Member Services Department reporting to Member Services Operations Director.

Educates providers, staff and members on Health Plan benefits and services and applicable regulations. Accountable for accurate and timely identification, investigation and processing of all member / patient inquiries.

Responsible for intake and resolution of End Of Next Business Day (ENB) complaint and grievance cases within the Medical Center and medical offices.

Responsible for partnering with internal and external staff and departments to provide creative, timely solutions for member concerns.

Assists with training, audits and other activities as necessary. Negotiates with Medical Center, service area and regional staff, as necessary to reach satisfactory service solutions to issues that optimize our members experience with the services they receive.

Demonstrates a commitment to serving internal and external customers. Promotes and represents Kaiser Permanente effectively, both on-the-job and in the community.

Essential Responsibilities :

• Upholds Kaiser Permanentes Policies and Procedures, Principles of Responsibilities and applicable state, federal and local laws.
• Act as liaison between the patient / member, external clients, and Kaiser Permanente in providing general assistance and education on how to utilize the Kaiser system, resolve member ENB complaints and grievances as efficiently as possible, and answer Health-Plan related questions.
• Partner with other departments in the organization, such as Marketing and Health Education, and attends community, employer and KP events to ensure accurate information is provided to various clientele regarding KP services, benefits, and protocols.
• Educate providers, staff and individual members on Health Plan benefits and services and applicable regulations.
• Effectively handle and attempt to resolve member issues that are received from numerous sources.
• Appropriately transfer all applicable cases and accompanying documentation after initial resolution effort.
• Appropriately interview member / patient (or authorized representative of patient) in person or via phone regarding benefit, service, and medical care issues.
• Accountable for investigation of all ENB and inquiry issues, including collection and documentation of appropriate data.
• Responsible for communicating with members or their authorized representative(s), regarding the Health Plans response and grievance / complaint process.
• Ensure that inquiry and ENB documentation and processing are completed in accordance with regulations, compliance standards, policies and procedures.
• Regulators include, but are not limited to : Center for Medicare / Medicaid (CMS), California Department of Managed Healthcare (DMHC), Department of Health Services (DHS), Department of Labor, Department of Consumer Affairs, the National Committee for Quality Assurance (NCQA).
• Document, and triage all case information to Member Case Resolution Center (MCRC) after attempting to resolve applicable cases via the ENB process.
• Partner with Member Case Resolution Center to resolve member complaints, grievances and appeals within regulatory timeframe per established protocols and service level agreements.
• 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 applicable Policies and Procedures and effectively manages case inbox on a daily basis.
• Participate in departmental and Medical Center meetings, trainings and audits as requested.
• Educate members / patients about their rights and responsibilities, medical center services, policies and procedures.
• Identifies member - system conflict in an effort to prevent professional liability, minimize financial penalties to the organization, and retain satisfied members.
• Communicate continually with a diverse set of internal and external clientele to achieve excellent results in the areas of complaint and grievance handling, compliance, documentation, benefit / contractual information, and enhancement of the member experience.
• Partner with and outreach to internal staff, managers and physicians, to identify opportunities to advocate for the member and resolve issues as quickly as possible.
• Create effective partnerships between Call Center and Member Services at the Medical Center to work collaboratively in responding to and resolving investigative complaints that are received at the call center Negotiate with facility, service area, and regional staff (as necessary) to reach satisfactory service solutions to issues that optimize our members experience with the services they receive.
• Effectively utilize service strategies and actively participate in Medical Center service initiatives and activities.
• Conduct self-audits of work, to ensure quality and compliance.
• Answer questions and manage members on existing / open cases Assist non-English or limited-English speaking customers in the use of interpreter services.
• Perform other duties, as required Assume other activities and responsibilities from time to time as directed.
• Assume other activities and responsibilities from time to time as directed.

Basic Qualifications :

Experience

Minimum one (1) year of experience in a customer service environment where customer service, problem solving, and compliance with regulatory requirements were the main components of the job.

Education

High School Diploma or General Education Development (GED) required.

License, Certification, Registration

N / A

Additional Requirements :

• Strong working knowle

Last updated : 2024-06-15