Incident Management Specialist III, Grievances and Appeals

About the role

This position coordinates and monitors the resolution of grievances and appeals cases by investigating, communicating with members and their advocates both verbally and in writing, and preparing presentations of all relevant documentation to medical committees for medical service determinations and reconsiderations. The role involves identifying and partnering with appropriate entities to process escalations with elevated complexity, reviewing cases to confirm documentation readiness, and leveraging foundational knowledge of the product/service domain to contribute to satisfactory resolutions of moderately complex customer and member grievances and appeals.

Additional responsibilities include resolving issues related to health care delivery, benefits, or financial barriers by collaborating with cross-functional partners, recognizing service gaps that contribute to dissatisfaction, making decisions on appropriate case types using critical thinking within policy and guidelines, and ensuring compliance with external regulations and responses to regulators.

Responsibilities

• Proactively provides resources, information, advice, and expertise to coworkers and members; listens to and addresses performance feedback; mentors team members.
• Pursues self-development; creates plans to capitalize on strengths and develop weaknesses; influences others through technical explanations and examples.
• Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in work approaches; supports others in adapting to new tasks and processes.
• Supports and responds to the needs of others to achieve business outcomes.
• Completes work assignments autonomously using up-to-date expertise; ensures adherence to procedures and policies; leverages data and resources to support projects or initiatives.
• Collaborates cross-functionally to solve business problems; escalates issues or risks as appropriate; communicates progress and information.
• Identifies, monitors, and supports priorities, deadlines, and expectations; implements improvement opportunities for the team.
• Performs member, customer, or employee incident case management by monitoring and analyzing case tracking databases, processing moderately complex and specialty/flagged cases, and ensuring compliance with internal and external rules.
• Investigates claims, authorizations, member contracts, and customer service interactions to make determinations for moderately complex and specialty/flagged cases.
• Resolves moderately complex or specialty/flagged incident cases by interacting with business leaders and stakeholders, implementing case decisions, and communicating outcomes.
• Provides accurate information to members, customers, or stakeholders regarding case status and outcomes; diffuses frustrated or emotional stakeholders in highly charged situations.
• Maintains confidentiality of member, customer, or employee information; documents cases in accordance with internal and external requirements.

Requirements

• Minimum one (1) year of experience in customer service or a directly related field.
• Bachelor’s 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.

Skills

• 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 Qualifications

• Three (3) years of health-care compliance or regulatory experience in National Committee for Quality Assurance (NCQA), Medicare, Medicaid, or Joint Commission.

Schedule

• Full-time
• Day shift: Monday–Friday, 08:00 AM–05:00 PM
• Scheduled weekly hours: 40

Pay

Pay range: $29.08 - $37.60 per hour. Actual base pay determined at offer will be based on labor market data, internal alignment, and a candidate's years of relevant work experience, education, certifications, skills, and geographic location.

Work Setting

• Remote (worker location must align with Kaiser Permanente's Authorized States policy)
• No travel required