Description and Requirements

Location: Fully Remote Work Arrangement: Remote within Corona, CA Education Required: High School Diploma Education Preferred: College Degree

Position Overview

The Case Manager will participate in managing the organization's complaint and grievance process, including investigating issues, collecting and documenting information, coordinating with internal stakeholders, and communicating resolutions to members and their authorized representatives.

This role requires strong communication, organization, problem-solving, and conflict-resolution skills. The ideal candidate will be comfortable managing sensitive and complex member issues in a time-sensitive environment while ensuring compliance with applicable regulations, policies, and procedures.

Major Responsibilities

• Participate in managing the organization's complaint and grievance process.
• Investigate complaints and grievances, including collecting and documenting appropriate information and data.
• Identify and appropriately manage specialty and flagged cases, following established processes for different case types.
• Communicate with a diverse group of internal and external stakeholders to achieve positive outcomes in complaint and grievance handling, compliance, documentation, and member experience.
• Partner with and conduct outreach to internal staff, other departments, managers, and physicians to resolve issues as quickly as possible.
• Research, resolve, and communicate complaints and grievances submitted by members.
• Communicate Health Plan decisions appropriately to members or their authorized representatives.
• Ensure complaints and grievances are processed in accordance with applicable regulations, compliance standards, policies, and procedures.
• Meet required performance timeframes while maintaining high-quality work related to complex and sensitive member issues.
• Maintain the integrity of departmental databases through thorough, timely, and accurate data entry consistent with regulatory requirements.
• Effectively manage the case resolution inbox on a daily basis.
• Answer questions and assist members with existing or open cases.
• Escalate issues to management as appropriate to maintain compliance and support appropriate case resolution.
• Participate in departmental meetings, training sessions, and audits as requested.

Required Qualifications

• High School Diploma or equivalent.
• Experience in a service-related industry.
• Excellent interpersonal, verbal, and written communication skills.
• Ability to work effectively with peers in a self-managed team environment.
• Strong organizational skills with the ability to prioritize work and meet required deadlines.
• Ability to ensure all required compliance elements are completed accurately and timely.
• Demonstrated conflict-resolution and mediation skills.
• Ability to effectively communicate with and obtain action from multiple stakeholders.
• Ability to exercise sound judgment and independently manage complex issues.
• Ability to recognize when escalation or additional assistance is needed.
• Demonstrated ability to work effectively in a time-sensitive environment involving patients, family members, and advocates.

Preferred Qualifications

• College degree.
• Call center experience.
• Experience handling complaints, grievances, escalations, or complex customer/member service issues.
• Experience working in a healthcare, health plan, insurance, or other regulated environment is a plus.

Work Environment & Additional Details

• This is a fully remote position within Corona, CA
• Equipment will be provided; however, contingent workers should be aware that equipment delivery/setup may take up to 14 days.
• Occasional in-person attendance may be required if an issue involving network connectivity, power, equipment, or another circumstance requires the contingent worker to report to the office.

High school diploma or equivalent; experience in a service-related industry; strong communication, organizational, conflict-resolution, and mediation skills; ability to manage complex issues and meet deadlines.

Key Responsibilities

• investigating complaints
• documenting information
• communicating resolutions

Job Details

• Category: Healthcare Services - Allied Health
• Seniority: Entry Level
• Commitment: Full Time
• Workplace: Remote — Corona, California, United States
• Languages: English

About Kaiser Permanente

A healthcare organization providing health plans and medical care. — Industry: Healthcare