Partnership HealthPlan of California · 2 months ago
State Hearing Representative
US-CA-Fairfield
Full-time
Onsite
Mid, Senior Level
$94K/yr - $117K/yr
3+ years expPartnership HealthPlan of California is a managed care organization, and they are seeking a State Hearing Representative. This role is responsible for managing State Hearings and court cases for members contesting Appeals and Grievances decisions, ensuring compliance with regulations while providing expert guidance throughout the process.
Health CareInsuranceNon Profit
Responsibilities
Represents Partnership HealthPlan of California in State Hearings. Serves as an expert in handling and resolving the spectrum of member issues reported in all grievances and appeals cases
Works independently and exercises excellent judgement in representing Partnership HealthPlan at State Hearings
Responsible for completion of entire lifecycle of assigned State Hearing cases: Self-assigns case on CDSS Appeals Case Management System (ACMS), manages all case-specific activities in Everest, conducts case research, coordinates with Medical Directors, collaborates with legal, prepares legal documents, conducts hearing, and executes court decisions
Demonstrates empathy and works calmly with dissatisfied members
Consistently practices the handling of PHI/PII data with sensitively and strict confidentiality
Negotiates with members to withdraw state hearings by rectifying problems
Collaborates with the Regulatory and Affairs Department to ensure Partnership HealthPlan of California’s best interest is represented throughout state hearing process
Communicates case hearing decisions to management
Serves as an expert on State Hearing processes, guidelines, laws, and best practices. Creates desktops, policy & procedures to ensure compliances with all regulatory and industry requirements. Will train staff on State Hearings as needed
Based on lessons learned from State Hearing trends, provides recommendations to management that reduces State Hearings through improved best practices
Handles Americans with Disabilities Act (ADA) 1557 discrimination grievances
May handle very high-profile grievance and/or appeal cases
May handle sensitive complaints against Partnership Health Plan of California staff
May assist with the development of internal audit criteria and practices
May attend and represent Grievance & Appeals in internal committees
May serve as a back-up to audit Grievance & Appeals staff
May serve as a back-up to Grievance & Appeals Supervisor
May conduct training to onboarding new Grievance & Appeals staff
Attends and may facilitate departmental meetings
Completes all State Hearing and casework according to DHCS, NCQA, and Grievance & Appeals mandated timeframes and best practices
Must be available after normal work hours and/or weekends to ensure Partnership HealthPlan of California meets all obligations accurately and timely
Conducts other projects, initiatives, and/or duties as assigned
Qualification
Required
Bachelor's degree in related field
Minimum five (3) years' experience in a managed care health insurance environment
Three (3) years' experience processing Grievance and Appeals cases
Experience with CDSS State Hearing cases a plus
Paralegal experience in a health care environment is a plus
Thorough working knowledge of managed care concepts, policies, and procedures
Knowledge of grievance and appeal regulations (e.g. Title 10 CCR, Title 22 CCR, Title 28 CCR, Health and Safety Code 1340 et seq., 42 CFR 422 and 423, Medicare Managed Care and Prescription Drug Manuals, etc.)
Ability to understand, interpret, and prepare documentation used in legal cases
Working knowledge of business software applications
Advanced experience with Windows and related applications
Familiarity with database applications
Knowledge of medical terminology and ability to understand and interpret medical decisions
Proficient use of computer keyboard to access data
Valid California driver's license or the ability to secure alternative transportation
Strong leadership skills
Ability to work independently, with minimal supervision
Ability to assess and resolve customer complaints, problems, and issues in an effective manner
Demonstration of conflict resolution and mediation skills
Ability to interview and investigate emotional situations with a level of sensitivity and understanding
Excellent written and verbal communication skills
Ability to listen effectively and appropriately respond to difficult and/or urgent situations
Attention to detail and excellent organizational skills
Ability to multitask and manage time
Excellent analytical and interpersonal skills
Ability to prioritize issues and handle sensitive issues with confidentiality, tact, and diplomacy
Decision-making and critical thinking skills
Ability to cope and deal with a high volume of tasks and demanding situations
Adaptable to a constantly changing environment
Ability to work independently and with a team
Preferred
Bilingual skills in Spanish, Tagalog, or Russian may be required
Paralegal training desired
Company
Partnership HealthPlan of California
Partnership HealthPlan of California is a non-profit community-based health care organization that contracts with the state to administer Medi-Cal benefits through local care providers to ensure Medi-Cal recipients have access to high-quality comprehensive cost-effective health care.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
L
Lorna Veloso
Sr. Manager of OpEx/PMO
Recent News
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