PC3 Escalations Specialist at Centene in Manchester, NH

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HourlyPosition Purpose: 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.

  • 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.
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