We are seeking a BPC-Subject Matter Expert-Contractor for one of our important clients.
Candidates will be participate in managing the organization's complaint and grievance process for Member Services.
Serves as Case Manager in managing the organization's closure of Expedited Appeals and processing
External Independent Medical Review cases, including:
nvestigates all appeals, including collection of appropriate documentation
Participates in the Expedited rounds with Nurse Case Managers and Medical Director
Responds to members, their physicians, and authorized representatives regarding the Health
Prepares appeals for external independent medical review and other state and federal
Coordinates with medical center HP/H and PMG leaders member's care when external
independent medical reviewer overturns the Plan's determination.
Prepares all cases in accordance with regulations, compliance standards, and policies and procedures. Partners with other health plan departments, Company's Hospital staff, and PMGs in handling complex issues, politically sensitive issues including documentation, file maintenance, negotiation, resolution and response.
Mentors and serves as consultant to area health plan staff, and other local and divisional entities requiring expertise and advice regarding meeting regulatory requirements or problem solving member grievances.
Serves as a case manager in the investigation, preparation and presentation of Health Plan's member termination for cause.
Represents Health Plan in Administrative Law Judge cases. Participates in departmental meetings, trainings,
and unit self audits as requested.
Responsible for the investigation, presentation and resolution of expedited member case appeals (24-72 hour turn around) and Federal
and State mandated external independent medical review. Responsible for documentation to terminate members for cause from
Health Plan. Responsible for representing Company Health Plan in Administrative Law Judge cases