Provide non-clinical support to the Customer Solution Center Appeals and Grievance Specialists for L. A. Care's Medicare Advantage program. This includes the technical aspects of the time sensitive processes for initiating cases, managing referral documentation, entering pre-certification/continued authorizations, identifying and responding to urgency of the request, appropriate documentation, case routing & tracking, routing of information, performing computer data input, faxing, filing of confidential member information, and maintaining logs of activity, etc.). (40%)
Assist in the telephonic outreach calls to members identified during health risk assessments as in needed of care coordination assistance. Consist of follow up calls to members to administer screening or obtaining clarification on initial responses. (25%)
Under the supervision of the Appeals and Grievance Manager, assist with soliciting non-clinical information from Participating Physical Group (PPG) and specialist concerning follow care related to care management. (15%)
Maintain the monthly reporting responsibilities, Appeals and Grievance reporting to Department Director, ongoing referrals and authorizations for members in complex care management. (5%)
Accurately maintain an updated log of L.A. Care members identified as SPD or eligible with CCS cases. If members become ineligible with L.A Care or a specific program members are referred to Member Services for transition to other applicable programs". (5%)
Perform other duties as assigned. (10%)