Overview

The State Hearing Representative has overall responsibility for assigned State Hearings, court cases for Partnership members contesting the outcome of Appeals and/or Grievances decisions. This position will represent Partnership HealthPlan of California at Department of Social Services (CDSS) court hearings. Responsible for establishing course of action to resolve conflict with Partnership members, case research, preparation of legal documents, coordination of internal resources, submission of cases to CDSS, conducting case hearings, and final outcome. Negotiates case withdrawals with Partnership members. May handle ADA 1557 discrimination cases. May handle high-profile and staff-complaint grievance and/or appeal cases. Provides expert guidance to Grievance & Appeal Coordinators on complex casework.

Responsibilities

• Represents Partnership HealthPlan of California in State Hearings. Serves as an expert in handling and resolving the spectrum of member issues reported in all grievances and appeals cases
• Works independently and exercises excellent judgement in representing Partnership HealthPlan at State Hearings
• Responsible for completion of entire lifecycle of assigned State Hearing cases: Self-assigns case on CDSS Appeals Case Management System (ACMS), manages all case-specific activities in Everest, conducts case research, coordinates with Medical Directors, collaborates with legal, prepares legal documents, conducts hearing, and executes court decisions.
• Demonstrates empathy and works calmly with dissatisfied members
• Consistently practices the handling of PHI/PII data with sensitively and strict confidentiality.
• Negotiates with members to withdraw state hearings by rectifying problems
• Collaborates with the Regulatory and Affairs Department to ensure Partnership HealthPlan of California’s best interest is represented throughout state hearing process
• Communicates case hearing decisions to management
• Serves as an expert on State Hearing processes, guidelines, laws, and best practices. Creates desktops, policy & procedures to ensure compliances with all regulatory and industry requirements. Will train staff on State Hearings as needed
• Based on lessons learned from State Hearing trends, provides recommendations to management that reduces State Hearings through improved best practices
• Handles Americans with Disabilities Act (ADA) 1557 discrimination grievances
• May handle very high-profile grievance and/or appeal cases
• May handle sensitive complaints against Partnership Health Plan of California staff
• May assist with the development of internal audit criteria and practices
• May attend and represent Grievance & Appeals in internal committees
• May serve as a back-up to audit Grievance & Appeals staff
• May serve as a back-up to Grievance & Appeals Supervisor
• May conduct training to onboarding new Grievance & Appeals staff
• Attends and may facilitate departmental meetings
• Completes all State Hearing and casework according to DHCS, NCQA, and Grievance & Appeals mandated timeframes and best practices
• Must be available after normal work hours and/or weekends to ensure Partnership HealthPlan of California meets all obligations accurately and timely

SECONDARY DUTIES AND RESPONSIBILITIES

• Conducts other projects, initiatives, and/or duties as assigned

Qualifications

MINIMUM HIRING CRITERIA

Education and Experience

Bachelor's degree in related field; minimum five (3) years’

experience in

a managed care health insurance environment; (3) years’ experience

processing Grievance and Appeals cases; experience with CDSS State

Hearing cases a plus; paralegal experience in a health care environment

is a plus; or equivalent combination of education and experience.

Special Skills, Licenses and Certifications

Thorough working knowledge of managed care concepts, policies, and

procedures, including but not limited to, knowledge of grievance and

appeal regulations (e.g. Title 10 CCR, Title 22 CCR, Title 28 CCR, Health

and Safety Code 1340 et seq., 42 CFR 422 and 423, Medicare Managed

Care and Prescription

Drug Manuals, etc.). Ability to

understand,

interpret, and

prepare documentation used in legal cases. Paralegal

training desired . Working knowledge

of business

software

applications.

Advance

experience

with

Windows

and

related

applications. Familiarity

with data

base applications. Knowledge of

medical terminology and ability to

understand and interpret

medical

decisions. Proficient use of computer

keyboard to access data. Bilingual

skills in Spanish, Tagalog, or Russian

may be required. Valid California

driver’s license or the ability to secure

alternative transportation may be

required.

Performance Based Competencies

Strong leadership skills are required. Must be comfortable holding people accountable for quality of work and have the ability to determine if casework did not meet department standards. Ability to work independently, with minimal supervision, and complete tasks within established strict time frames. Ability to use sound/professional judgment and to handle complex issues independently but with the knowledge and ability to escalate and ask for assistance when needed. Ability to assess and resolve customer complaints, problems, and issues in an effective manner. Demonstration of conflict resolution and mediation skills. Ability to interview and investigate emotional situations with a level of sensitivity and understanding. Consistently demonstrate the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to internal staff, members, and providers. Professional phone etiquette and customer service orientation necessary. Ability to learn quickly and acquire in-depth knowledge of software used at Partnership. Excellent written and verbal communication skills with the ability to write comprehensive statements, summaries, and prepare reports using proper grammar and sentence structure. Ability to listen effectively and appropriately respond to difficult and/or urgent situations. Attention to detail and excellent organizational skills are required. 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. Excellent and very thorough follow through skills. Excellent analytical and interpersonal skills and the ability to problem solve creatively, objectively, and rapidly. Ability to prioritize issues, use good judgment skills, and handle sensitive issues with confidentiality, tact, and diplomacy. Decision-making and critical thinking skills are required.

Display great initiative and ability to sense urgency. Ability to cope and deal with a high volume of tasks and demanding situations. Adaptable to a constantly changing environment and ability to work independently and with a team is a must.

Work Environment And Physical Demands

Ability to use a computer keyboard. More than 80% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects, weighing up to 25 lbs.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$93,690.86 - $117,113.58

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

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