The PC3 Escalations Specialist position is responsible for effectively and efficiently resolving escalated care issues and special handling of such issues. Initial actions will include reviewing authorizations and/or appointing requests for accuracy, and resolving authorization and/or appointing requests. The Specialist fully understands all aspects of the program and communicates effectively with Veterans, Providers and with VA Representatives. The Specialist thoroughly reviews, performs root cause analysis and works with the business to ensure the problem is solved.
Essential Duties & Responsibilities
- Demonstrates regular, reliable and predictable attendance.
- Provides customer service support to Veterans’ Administration Medical Center (VAMC) veterans customers with enrollment, benefits, access to care and claims issues.
- Immediately and thoroughly researches each escalated case to identify root cause and estimate level of severity and impact (e.g., customer service staff coaching opportunity, potential delay of care, etc.)
- Seeks any necessary supporting information from Veteran, Providers, VA, and medical management department.
- As needed, seeks guidance from Health Net's Medical Directors to facilitate expedient and appropriate appointing.
- Keeps Veteran and Health Net's management informed of resolution process and provides ongoing education to Veteran, Providers and VA.
- Notifies immediate supervisor of delays in resolving escalated situations within established escalation management guidelines and continues to manage any case which has not yet been resolved to the satisfaction of involved parties.
- Provides feedback to supervisors and quality assurance team on coaching opportunities.
- Informs senior management, Congressional Relations and Grievances, and legal of any perceived liabilities, including Potential Quality of Care (PQI) Issues.
- Thoroughly and completely documents communication with Veteran, Providers, VA or others engaged in resolving the issues.
- Accurately enters required information into the system of record.
- Utilizes escalation data to track and trend issues for management intervention and potential discussions with the Department of Veterans Affairs.
- Ensures compliance with program requirements, performs audits, identifies areas for improvement and participates on the teams convened to analyze process issues and correct any areas of vulnerability.
- Performs or supports required quality assurance activities as prescribed by the quality office and functional business owners.
- Other duties as assigned.
Bachelor’s degree in Health Care Admin or related field or equivalent experience
Government Clearance & US Citizenship Requirement
Requires US citizenship
- 3 years healthcare industry experience including medical terminology
- 2 year customer service/dispute resolution or equivalent role
- Managed care and Military/Veteran healthcare experience preferred
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.
Knowledge, Skills & Abilities
- Knowledge and understand of all aspects of the programs, and ability to communicate effectively with Veterans, Providers and with VA representatives
- Ability to maintain professional and technical knowledge of department procedures and technology
- Knowledge of medical terminology
- Excellent interpersonal, written and verbal communication skills
- The following section describes the general physical requirements for this position. Please note that ‘constant’ refers to more than 81% of time; ‘significant’ refers to 40-80%; and ‘moderate’ refers to 20-40% of the time.
- Operates personal computers, printers, facsimile, telephones, copy machines and other commonly used office accessories/equipment.
- Exposed to confidential information and expected to maintain confidentiality at all times; must adhere to HIPAA rules and regulations.
- May be required to work outside of normally scheduled hours as mandated by the client, project and/or workload (e.g. evenings, weekends, and/or holidays).
- May be required to maintain established work pace, meet deadlines; may have last minute urgent requests.
- Physical activity may include: twisting, reaching, kneeling, bending, stooping, squatting, crawling, grasping, grabbing, pushing, pulling, repetitive motion, climbing, etc.
- Required to have visual acuity to determine the accuracy, neatness, and thoroughness of the work assigned.
- Required to have hearing ability to receive detailed information through oral communication.
- Required to have speaking ability to express or exchange ideas.
- Constant concentration may be required on various subjects by listening, reading and thinking clearly.
- Interaction with others may be required. May need to listen, think, and speak in order to interact with others. Business interactions and behavior between coworkers and/or external customers are required. This may require face-to-face or telephone interactions.
- Thinking at work may include listening, learning, analyzing, evaluating, and the ability to interpret what is seen and/or heard, or to link information from one issue to the next.
- Constant computer usage including typing and/or eye strain.
- Constant repetitive arm, wrist, hand and finger motions -- making repetitive movements (e.g. key boarding, filing, data entry).
- Significant phone usage; headsets may be required.
- Moderate travel may be required between work sites and/or out of area.
- Significant amount of time spent working in a loud office environment with frequent interruptions/distractions.
- Constant sedentary work (desk bound or seated).
- Constant reading is required via computer screen and/or bound printed materials.
- Moderate walking/standing may be required. Walking and/or transporting supplies and equipment between buildings/parking lots and structures may be required.
DISCLAIMER: The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this job. They are not intended to be construed as an exhaustive list of responsibilities, duties and skills required of personnel so classified.
Location: Richmond, VA
Health Net and its subsidiaries are an Equal Opportunity/Affirmative Action Employer - Minorities/Females/Veterans/Disability