• Consult with Legal, Contracts & Coverage, Membership and other various areas within Kaiser Permanente. Know Healthcare Insurance conceptual knowledge. Present and explain regulations policies, or procedures.• Prepare and coordinate physician medical necessity reviews with the Clinical & Quality Review Unit and detailed case summary packets for review by Kaiser Permanent’s Appeals Committee and external review organizations. • Maintain organizational integrity and to enhance/increase… Show more • Consult with Legal, Contracts & Coverage, Membership and other various areas within Kaiser Permanente. Know Healthcare Insurance conceptual knowledge. Present and explain regulations policies, or procedures.• Prepare and coordinate physician medical necessity reviews with the Clinical & Quality Review Unit and detailed case summary packets for review by Kaiser Permanent’s Appeals Committee and external review organizations. • Maintain organizational integrity and to enhance/increase overall member satisfaction through appeal resolutions. • Follow all investigations and communications are HIPAA compliant. • Participate in value map streaming; analyzing current state and designing a future state of quality practice in appeals• Manage heavy caseload of up to 90 cases and maintain a 95%+ accuracy rate with strict time constraints from the Office of Insurance Commission and regulation of RCWs with 14-30 days to completion.• Cognizant of time, expense, and accuracy in interpreting insurance contracts by thoroughly reading and understanding contextual information to each appeal request. Show less

• Interview clients individually, in families, or in groups, assessing their situations, capabilities, and problems to determine what services are required to meet their needs with a 98% in accuracy in all areas of reporting child and family needs.• Serve as liaisons between students, homes, schools, family services, child guidance clinics, courts, protective services, doctors, and other contacts to help children who face problems, such as disabilities, abuse, or poverty… Show more • Interview clients individually, in families, or in groups, assessing their situations, capabilities, and problems to determine what services are required to meet their needs with a 98% in accuracy in all areas of reporting child and family needs.• Serve as liaisons between students, homes, schools, family services, child guidance clinics, courts, protective services, doctors, and other contacts to help children who face problems, such as disabilities, abuse, or poverty. • Provided crisis counseling and intervention while maintaining court deadlines, completing comprehensive reports, correspondence, and triaging 50% of caseload daily activities.• Assess need for out-of-home placement; prepares and counsels adults and children regarding the need for placement, separation of family members and loss trauma, and the steps for reunification; Show less