Kaiser Permanente Manager Benefits and Appeals in Renton, Washington

This Manager role is responsible for the Benefits Administration departments and the Appeals department for all lines of business. This accountability includes consistent and compliant benefits administration and configuration. Responsibilities include: ensuring contract compliance with regulatory requirements specific to state (WA and Idaho) and federal law. Responsible for ensuring Medicare and Commercial coverage policies are accurate and up to date. This also includes oversight of the Appeals department in support of timely and compliant operations. Maintain a strategic and effective system of oversight for benefits administration and appeals. Cultivate relationships and collaborate with key stakeholders to ensure the organization has and maintains appropriate practices and training.

Essential Responsibilities:

  • Managerial accountability for: the production, regulatory filing, printing and mailing of the benefit plan documents, and benefits configuration for all lines of business. This position also has accountability for the creation and maintenance of compliant coverage policies-for all lines of business. This position plays an integral role in corresponding with the WA state Office of the Insurance Commissioner and Department of Insurance in Idaho to ensure compliant filings.

  • Provides operational / strategic direction and support for Appeals and Benefits across the organization to include pre-certification, appeals management, and/or medical review. Directs the implementation of medical policy to ensure correct adjudication of claims in accordance with provider contracts, member contracts, legislative acts, and regulatory mandates. Identifies process and work flow issues as well as recommendations for improvement. Leads company project initiatives.

  • Manager responsibility to ensure compliant contract language and benefit policies are consistent with all Federal and State (WA/Idaho) regulatory requirements for KFHPW, KFHPWO and KPS Commercial and Medicare lines of business. Consults with internal stakeholders to develop benefit descriptions and contract language provisions. In collaboration with Compliance and Legal, provides expert consultation to internal stakeholders about regulatory requirements that influence contract language and/or benefit policies. Leads team to conduct analysis and review to identify key contract areas needing revision and approves language and riders developed.

  • Managerial responsibility for the creation of accurate CMS-required annual notification documents mailed in a timely manner to Medicare Advantage (MA) members; responsible for compliant preparation of Evidence of Coverage and Annual Notice of Change documents for MA members for GH/KFHPWO MA members compliant with Centers for Medicare and Medicaid Services guidelines. Responsible for accurate and updated benefit coverage policies and benefit interpretation to support Medicare and Commercial business.

  • Ensures departmental compliance with all organization-wide policies and all applicable state and federal regulations. Ensures all appeal/grievance activity is performed within regulatory guidelines (CMS, NCQA, ERISA, Dept. of Insurance Idaho State, Washington State Office of the Insurance Commissioner, etc.) and applicable policies and procedures meet the specified regulatory requirements. Understand and lead incorporation of new regulatory and other requirements into departmental policies and procedures.

Basic Qualifications:

Experience

  • N/A

Education

  • Bachelor's degree or higher in business, health care, compliance, communications, or public relations.

License, Certification, Registration

  • N/A

Additional Requirements:

  • Previous experience supervising staff with an emphasis on staff engagement.

  • Experience leading teams with competing priorities.

Preferred Qualifications:

  • Four (4) plus years of experience supervising staff with an emphasis on staff engagement.

  • Experience with benefits administration.

  • Experience with appeals and able to interact with regulators.

  • Experience in project management

  • Master's degree in business, health care, compliance, communications, or public relations.

  • MS Excel skills.

  • Written and verbal communicatons skills.

  • Solid understanding of state and federal regulations.

  • Compliance background.

COMPANY: KAISER

TITLE: Manager Benefits and Appeals

LOCATION: Renton, Washington

REQNUMBER: 695968

External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.