National Association of Latino Healthcare Executives · 14 hours ago
Incident Management Specialist III, Grievances and Appeals
Portland, OR
Full-time
Onsite
Mid LevelThe National Association of Latino Healthcare Executives is seeking an Incident Management Specialist III to coordinate and monitor the resolution of grievances and appeals. The role involves investigating cases, communicating with members, and collaborating with cross-functional teams to resolve complex issues related to healthcare delivery and benefits.
Health CareHospitalMedical
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
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
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
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
Performs case documentation by maintaining confidentiality of member, customer, or employee information throughout numerous documentation activities for moderately complex or specialty/flagged cases
Qualification
Required
Coordinates and monitors the resolution of grievances and appeals cases by investigating, communicating with members and their advocates both verbally and in writing
Prepares presentations of all relevant documentation to medical committees for medical service determinations and reconsiderations
Identifies and partners with appropriate entities to process escalations with an elevated level of complexity and a heightened level of resolution
Reviews cases and confirms documentation is prepared for decision making processes
Leverages a comprehensive foundational knowledge of the product/service domain to contribute to satisfactory resolutions of moderately complex customer and member grievances and appeals
Resolves issues for members related to health care delivery, benefits, or financial barriers by collaborating with cross functional partners and leaders
Recognizes service gaps that contribute to dissatisfaction among customers, members, key stakeholders and/or functional areas with minimal guidance
Makes decisions on appropriate case types using their own critical thinking taking into account policy and guidelines
Ensures that all case management activities are compliant with external regulations and responses to regulators
Pursues effective relationships with others by proactively providing resources, information, advice, and expertise with coworkers and members
Listens to, seeks, and addresses performance feedback; provides mentoring to team members
Pursues self-development; creates plans and takes action 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 approaches to work
Helps others adapt to new tasks and processes
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
Collaborates cross-functionally to solve business problems; escalates issues or risks as appropriate
Communicates progress and information
Supports, identifies, and monitors priorities, deadlines, and expectations
Identifies, speaks up, and implements ways to address improvement opportunities for team
Performs member, customer, or employee incident case management by monitoring and analyzing the case tracking database
Processes moderately complex and specialty/flagged incident cases
Ensures 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
Makes 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
Interacts with business leaders and other stakeholders
Implements case decisions
Provides accurate information to members, customers, employees, or other stakeholders related to the status and outcomes of moderately complex or specialty/flagged cases
Communicates with and diffuses frustrated members, customers, or other stakeholders in moderately complex or specialty/flagged cases
Maintains confidentiality of member, customer, or employee information throughout numerous documentation activities
Documents moderately complex or specialty/flagged cases in accordance with all internal and external requirements
Company
National Association of Latino Healthcare Executives
The National Association of Latino Healthcare Executives is a hospital and healthcare organization.
Founded in 2005
11-50 employees
Funding
Current Stage
Early StageLeadership Team
Jackie Sifuentes, MBA, LSSYB
Co-Founder La Mesa Emerging Leaders Mentorship Program for Early Careerists
Company data provided by crunchbase