Incident Management Specialist V, Grievances and Appeals

In addition to the responsibilities listed below, this position also 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; identifying and partnering with appropriate entities to process escalations with an elevated level of complexity and a heightened level of resolution; reviewing cases and confirming documentation is prepared for decision making processes; leveraging an expert knowledgeof the product/service domain to negotiate satisfactory resolutions of highly complex customer and member grievances and appeals with appropriate groups and departments (e.g., Medical Group, Health Plan); resolving issues for members related to health care delivery, benefits, or financial barriers by driving cross functional partners and leaders to resolve member challenges; recognizing and reporting service gaps and trends that contribute to dissatisfaction among customers, members, key stakeholders and/or functional areas; making decisions on appropriate case types using critical thinking taking into account policy and guidelines; ensuring that all case management activities are compliant with external regulations and responses to regulators; and identifying and making recommendations on the resolution of reoccurring or complex issues to mitigate impact on business objectives.

• 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 and new responsibilities; adapts to and learns from 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 made; influences the completion of project tasks by others.


• Drives member or employee incident case management by: managing and analyzing the case tracking database and case management activities to identify highly complex trends to report to management; developing processes to manage incident cases for multiple specialties and across all lines of business, as well as processing specialty/flagged complex or high risk incident cases; and implementing compliance with internal and external rules and regulations in the performance of case management activities, including the monitoring of cases to ensure they are within regulatory timeframes and quality standards.


• Drives 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 highly complex and specialty or flagged incident cases and provides guidance on cases to other team members.


• Contributes to the resolution of member or employee incident cases by: making decisions regarding highly complex or specialty/flagged incident cases through interacting with business leaders and other stakeholders and monitoring the decisions of others; and developing processes to manage incident cases for multiple specialties and across all lines of business, as well as processing specialty/flagged complex or high risk incidents.


• Drives customer service by: providing accurate information to members, customers, employees, or other stakeholders related to highly complex or specialty/flagged case statuses and outcomes in an appropriate timeframe, as well monitoring information provided by other team members to ensure itis accurate and timely; and communicating with and diffusing frustrated members, customers, or other stakeholders for highly complex or specialty/flagged cases involving highly charged, sometimes emotional situations.


• Enhances case documentation efforts by: developing processes for the appropriate handling of documentation in addition to maintaining confidentiality of member, customer, or employee information throughout numerous documentation activities for highly complex or specialty/flagged cases; and documenting highly complex cases and trends in accordance with all internal and external requirements.


• Serves as an advocate for operational improvement by: leveraging highly advanced knowledge of the incident management process, industry standards, and observations during work to identify and develop solutions for service gaps that contribute to member, customer, employee, or provider dissatisfaction, avoidable incident cases, or member or customer retention issues; identifying operational problems and advocating for solutions to improve highly complex and specialized incident processing and satisfaction metrics; and working within team to evaluate data and trends to conduct root cause analysis and identify operational solutions at the market level.