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BPC-Subject Matter Expert-Contractor
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Job Description

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

Plan's determination.

Prepares appeals for external independent medical review and other state and federal

government review.

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.

Job Description:

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

Job Requirements

The ideal candidate will possess the following qualifications.

Candidates must have Dynamic Strong Communication skills both interpersonal and written. Candidate must have very strong ability to communicate verbally and in writing. Proven Customer Service Skills while working under pressure. Ability to multitask and superior organizational skills are a must. Manager looking for or prefers any of the following backgrounds: Coding, Billing, Pharmaceutical, Customer Service & Legal Background in Healthcare or Insurance Experience. Also candidates with journalism or strong writing background would be considered. Candidates must have proven ability to deal with difficult customers situations on the phone. Must have proven skills at defining and researching problems.

**Healthcare experience preferred.

Minimum number of years of experience required: Minimum three (3) years of HMO experience or comparable experience.

- Minimum three (3) years of HMO experience or comparable experience.

Additional Requirements:

-Strong knowledge of Expedited Appeals Process and External Independent Medical Review Regulations required.

- Strong working knowledge of federal and state laws and regulations related to health care and managed care organizations.

- Excellent interpersonal, verbal and written communication skills.

- Ability to work with peers in self-managed teams to meet deadlines.

- Demonstrated conflict resolution and mediation skills with ability to secure action from persons outside their supervision.

- Ability to use sound judgment and to handle potentially charged issues independently but with the knowledge and ability to escalate

and ask for help when needed.

- Ability to multitask and manage time in order to perform well on long-term projects while being flexible enough to assimilate short

term projects on an ongoing basis.

- Must be able to work in a Labor/Management Partnership environment.

- Strong working knowledge of federal and state laws and regulations related to health care and managed care organizations.

- May (or will) require some (or extensive) travel to the Service Areas and/or Regional offices across the Division.

- Personal transportation required for local Service Area travel.

- Must be able to work weekends and holidays.

-Must be able to work in a Labor/Management Partnership environment.

Job Snapshot

Employment Type Contractor
Job Type Admin - Clerical
Education 4 Year Degree
Experience At least 3 year(s)
Manages Others Not Specified
Industry Healthcare - Health Services
Required Travel Not Specified
Job ID jaATR97009
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BPC-Subject Matter Expert-Contractor


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