Job Description : - Receives responds, resolves & documents written & electronic member correspondence & performs service recovery to include member, regulatory & senior leadership complaints in accordance w / applicable regulatory requirements, external laws & accreditation standards.

Makes members / patients & their needs a primary focus of one's actions-Develops & sustains productive member / patient relationships.

Actively seeks information to understand member / patient circumstances, problems, expectations & needs. Builds rapport & cooperative relationships w / member / patients.

Considers how actions or plans will affect member-Responds quickly to meet member / patient needs & resolves problems.- Accountable for creating a culture of compliance, ethics & integrity.

Maintains knowledge of & assures departmental compliance w / KP's Principles of Responsibility & policies & procedures, & applicable regulatory requirements & accreditation standards.

Develops & maintains contact w / key individuals in research & resolution of complaints to insure timeliness of resolution of the provider / patient relationship- Provides appropriate financial services recovery up to w / additional amounts as authorized by member services leadership- Researches, confirms & issues benefit payment & medical necessity adverse determinations (denials) - Responds to fraud / abuse allegations committed by members evaluate, document, investigate, legitimize & determine appropriate plan of action, potentially resulting in terminating the member & their family(s) health insurance w / KPRequired Skills : -Experience responding to member benefit, or billing inquiries;

responding to Case Resolution quality issues or complaints.- Demonstrated experience w / multiple computer applications- Previous experience working w / all levels of management / providers- Candidate must be able to focus on quality and push to resolve issues.

Must have very strong verbal and written skills.- Must have proven sills at defining and researching problems. Desired skills-Experience in health care quality / complaint management- Experience w / regulatory & member fraud abuse-Healthcare experience preferredEducational Requirement : Bachelor's degree in a related area, e.

Last updated : 2024-05-12