RanchoCucamongaRecruiter Since 2001
the smart solution for Rancho Cucamonga jobs

MCRC Senior Consultant

Company: Kaiser Permanente
Location: Rancho Cucamonga
Posted on: May 24, 2023

Job Description:

ERU Sr. Consultant: Responsible for the investigation, presentation & resolution of expedited member case appeals (72 hour turn around). PDU Sr. Consultant: Responsible for the investigation, presentation & resolution of expedited & standard medicare Part D coverage determinations & redeterminations (24 to 72 hour turn around), & Part D grievances. CCU Sr. Consultant: Responsible for the investigation, presentation & resolution of member complaints & grievances that meet the MCRC complex case unit (CCU) criteria.Essential Functions:- Serves as Case Mrg in managing the organization's closure of Expedited Appeals, Part D coverage determinations & redeterminations, & MCRC grievances that meet the Complex Case Unit (CCU) criteria.- These include the following:- Investigates all complaints, grievances & appeals, including collection of appropriate documentation.- Participates in the Expedited rounds w/ Nurse Case Mrgs & Medical Director (ERU).- Participates in the Part D benefit committee.- In conjunction w/ TM, participates in Part D coverage decisions & facilitates MD review of medical necessity requests (PDU).- Participates in CCU weekly rounds & partners w/ clinical consultants.- In conjunction w/ TL/TM, participates in benefit decisions, facilitates MD review of medical necessity requests, & facilitates the appropriate level of internal review based upon case merits & organizational risk.- Is involved & partners w/ medical center & regional leadership to facilitate the appropriate review, resolution & service recovery for high profile, highly sensitive cases.- Makes initial & follow up contact w/ patient/member throughout the case & ensure patient's immediate needs are met timely (appointments, facilitating care) (CCU).- Responds to members, their physicians, & authorized representatives regarding the Health Plan's determination.- Prepares all cases in accordance w/ regulations, compliance standards, & policies & procedures.- Partners w/ other health plan Depts, KP Hospital staff, & PMGs in handling complex issues, politically sensitive issues including documentation, file maintenance, negotiation, resolution & response.- Mentors & serves as consultant to area health plan staff, & other local & divisional entities requiring expertise & advice regarding meeting regulatory requirements or problem solving member grievances.- Represents Health Plan in Administrative Law Judge cases.- Participates in departmental meetings, trainings, & unit self-audits as requested.- KP conducts compensation reviews of positions on a routine basis. At any time, KP reserves the right to reevaluate & change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees.- Consistently supports compliance & the Principles of Responsibility (KP's code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting w/ ethics & integrity, reporting non-compliance, & adhering to applicable Federal & State laws & regulations, accreditation & licensure requirements, & KP policies & procedures.- In addition to defined technical requirements, accountable for consistently demonstrating service behaviors & principles defined by the KP Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives.- Also accountable for consistently demonstrating the knowledge, skills, abilities, & behaviors necessary to provide superior & culturally sensitive service to each other, to our members, & to purchasers, contracted providers & vendors.

Keywords: Kaiser Permanente, Rancho Cucamonga , MCRC Senior Consultant, Professions , Rancho Cucamonga, California

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category

Log In or Create An Account

Get the latest California jobs by following @recnetCA on Twitter!

Rancho Cucamonga RSS job feeds