Kaiser Permanente Northwest · 6 hours ago
Incident Management Specialist III, Grievances and Appeals
Portland, OR
Full-time
Onsite
Mid, Senior Level
2+ years expKaiser Permanente Northwest is seeking an Incident Management Specialist III to coordinate and monitor the resolution of grievances and appeals cases. The role involves investigating cases, communicating with members, and ensuring compliance with regulations to resolve member challenges related to health care delivery and benefits.
Hospital & Health Care
Responsibilities
Pursues effective relationships with others by proactively providing resources, information, advice, and expertise with coworkers and members
Completes work assignments autonomously by applying up-to-date expertise in subject area to generate creative solutions; ensures all procedures and policies are followed; leverages an understanding of data and resources to support projects or initiatives
Performs member, customer, or employee incident case management by: monitoring and analyzing the case tracking database to identify moderately complex, specialty, or flagged cases that require resolution as well as reporting trends to management; processing moderately complex and specialty/flagged incident cases; and ensuring compliance of own work with internal and external rules in the performance of case management activities with some review necessary
Performs member or employee incident case research by: investigating claims, authorizations, member contracts, and/or customer service interactions across members and customers to make determinations for moderately complex and specialty or flagged incident cases
Resolves member or employee incident cases by: making decisions regarding moderately complex or specialty/flagged incident cases through interacting with business leaders and other stakeholders; and resolving moderately complex or specialty/flagged cases and implementing case decisions
Performs customer service by: providing accurate information to members, customers, employees, or other stakeholders related to the status and outcomes of moderately complex or specialty/flagged cases in an appropriate timeframe; and communicating with and diffusing frustrated members, customers, or other stakeholders in moderately complex or specialty/flagged cases involving highly charged, sometimes emotional situations
Performs case documentation by: maintaining confidentiality of member, customer, or employee information throughout numerous documentation activities for moderately complex or specialty/flagged cases; and documenting moderately complex or specialty/flagged cases in accordance with all internal and external requirements
Qualification
Required
Minimum one (1) year of experience in customer service or a directly related field
Bachelors degree in Business Administration, Economics, Health Care Administration, Health Services, Communications, or related field AND minimum two (2) years of experience in health care, health insurance, sales and marketing, or a directly related field OR Minimum five (5) years of experience in health care, health insurance, sales and marketing, or a directly related field
Knowledge, Skills, and Abilities (KSAs): Information Gathering; Negotiation; Incident Management; Health Care Compliance; Maintain Files and Records; Data Entry; Acts with Compassion; Interpersonal Skills; Managing Diverse Relationships; Relationship Building; Stakeholder Management; Incident Escalation; Managing Complexity; Time Management; Service Focus; Adaptability; Stress Tolerance; Member Service; Patient Safety; Microsoft Office; Incident & Complaint Processes; Conflict Resolution
Preferred
Three (3) years of health-care compliance or regulatory experience in National Committee for Quality Assurance, Medicare, Medicaid, or Joint Commission
Company
Kaiser Permanente Northwest
Kaiser Permanente is committed to helping shape the future of health care.
10001+ employees
Funding
Current Stage
Late StageLeadership Team
Karen Miles
Chief Operating Officer
Wendy Watson
Chief Operating Officer
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