Incident Management Specialist V, Grievances and Appeals

About the role

This position manages the resolution of grievances and appeals cases by investigating, communicating with members and their advocates both verbally and in writing, preparing presentations of all relevant documentation to medical committees for medical service determinations and reconsiderations. The role identifies and partners with appropriate entities to process escalations with elevated complexity, reviews cases to confirm documentation readiness, and leverages expert knowledge of the product/service domain to negotiate satisfactory resolutions of highly complex customer and member grievances.

Additional responsibilities include resolving issues related to health care delivery, benefits, or financial barriers by driving cross-functional collaboration, recognizing and reporting service gaps and trends, making decisions on case types using critical thinking within policy guidelines, ensuring compliance with external regulations, and recommending resolutions for recurring or complex issues to mitigate business impact.

Responsibilities

• Promotes learning in others by communicating information and providing advice to drive projects forward; builds relationships with cross-functional stakeholders.
• Listens, responds to, seeks, and addresses performance feedback; provides actionable feedback to others, including upward feedback to leadership, and mentors junior team members.
• Practices self-leadership; creates and executes plans to capitalize on strengths and improve opportunity areas; influences team members within assigned team or unit.
• Adapts to competing demands, new responsibilities, change, challenges, and feedback.
• Models team collaboration within and across teams.
• Conducts or oversees business-specific projects by applying deep expertise in subject area; promotes adherence to all procedures and policies.
• Partners internally and externally to make effective business decisions; determines and carries out processes and methodologies; solves complex problems; escalates high-priority issues or risks as appropriate; monitors progress and results.
• Develops work plans to meet business priorities and deadlines; coordinates and delegates resources to accomplish organizational goals.
• Recognizes and capitalizes on improvement opportunities; evaluates recommendations; influences the completion of project tasks by others.
• Drives member or employee incident case management by managing and analyzing case tracking databases, identifying complex trends, developing processes for multiple specialties and lines of business, and ensuring compliance with internal and external regulations.
• Investigates claims, authorizations, member contracts, and customer service interactions to make determinations for highly complex or specialty cases and provides guidance to other team members.
• Contributes to the resolution of member or employee incident cases by making decisions through interactions with business leaders and stakeholders, and developing processes for managing complex or high-risk incidents.
• Drives customer service by providing accurate and timely information to members, customers, or stakeholders regarding case statuses and outcomes, and diffusing emotionally charged situations.
• Enhances case documentation efforts by developing processes for appropriate handling and confidentiality of member information, and documenting complex cases in accordance with internal and external requirements.
• Serves as an advocate for operational improvement by identifying service gaps, advocating for solutions to improve incident processing and satisfaction metrics, and conducting root cause analysis to identify operational solutions.

Requirements

• Minimum four (4) years of experience in customer service or a directly related field.
• Minimum three (3) years of experience in a leadership role with or without direct reports.
• Bachelor’s degree in Business Administration, Economics, Health Care Administration, Health Services, Communications, or related field AND minimum seven (7) years of experience in health care, health insurance, sales and marketing, or a directly related field OR minimum ten (10) 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
• Benefits/Services Knowledge
• Conflict Resolution
• Interpersonal Skills
• Managing Diverse Relationships
• Relationship Building
• Stakeholder Management
• Incident Escalation
• Managing Complexity
• Time Management
• Service Focus
• Investigations Management
• Adaptability
• Stress Tolerance
• Member Service
• Patient Safety
• Microsoft Office
• Presentation Skills
• Incident & Complaint Processes
• Business Process Improvement
• Trend Analysis

Preferred Qualifications

• Five (5) years of health-care compliance or regulatory experience in National Committee for Quality Assurance (NCQA), Medicare, Medicaid, or Joint Commission.
• Master’s Degree or equivalent or higher in nursing, business administration/management, health care administration/management, operations research, public health administration, call center management, or related field.

Schedule

• Full-time
• Shift: Day (Monday–Friday)
• Working Hours: 08:00 AM – 05:00 PM
• Scheduled Weekly Hours: 40
• Travel: Yes, 25% of the time
• Work Setting: Flexible (worker location must align with Kaiser Permanente's Authorized States policy)

Pay

$117,900 – $152,570 per year. Kaiser Permanente strives to offer a market-competitive total rewards package and is committed to pay equity and transparency. The posted pay range is based on possible base salaries for the role and does not reflect the full value of the total rewards package. 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.