Healthplan Representative

Kaiser Permanente • San Marcos, CA

406d

About The Position

The Healthplan Representative position at Kaiser Permanente is responsible for educating providers, staff, and members about Health Plan benefits and services while ensuring compliance with applicable regulations. This role involves investigating and processing member inquiries, complaints, and grievances, and requires effective communication and problem-solving skills to enhance the member experience. The representative acts as a liaison between members and the organization, promoting Kaiser Permanente's services and values in the community.

Requirements

• Minimum one (1) year of experience in a customer service environment with a focus on problem solving and compliance with regulatory requirements.
• High School Diploma or General Education Development (GED) required.
• Strong working knowledge of federal and state regulations related to health care and managed care organizations.
• Demonstrated ability to handle a high volume of contact with customers.
• Strong understanding of health plan terminology required.
• Ability to interview and investigate emotional situations with sensitivity and understanding.
• Excellent interpersonal/verbal communication skills.
• Demonstrated conflict resolution and mediation skills.

Nice To Haves

• Customer service training preferred.
• Knowledge of member complaint and grievance processing preferred.
• Bilingual skills preferred.
• Bachelor's degree preferred.

Responsibilities

• Educate providers, staff, and members on Health Plan benefits and services and applicable regulations.
• Act as a liaison between the patient/member, external clients, and Kaiser Permanente.
• Research, resolve, and communicate Health Plan/coverage-related issues for members.
• Effectively handle and attempt to resolve member issues from various sources.
• Accountable for investigation of all ENB and inquiry issues, including documentation of appropriate data.
• Communicate with members regarding the Health Plan's response and grievance/complaint process.
• Ensure inquiry and ENB documentation are completed in accordance with regulations and compliance standards.
• Document and triage all case information to the Member Case Resolution Center after initial resolution efforts.
• Partner with the Member Case Resolution Center to resolve member complaints and grievances within regulatory timeframes.
• Participate in departmental and Medical Center meetings, trainings, and audits as requested.
• Educate members/patients about their rights and responsibilities, medical center services, policies, and procedures.
• Identify member-system conflicts to prevent professional liability and retain satisfied members.
• Create effective partnerships between Call Center and Member Services to collaboratively respond to complaints.
• Conduct self-audits of work to ensure quality and compliance.

Benefits

• Health insurance coverage
• Dental insurance coverage
• Vision insurance coverage
• 401k retirement savings plan
• Paid holidays
• Paid time off (PTO)
• Flexible scheduling options

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Ambulatory Health Care Services
• Education Level: High school or GED