Kaiser Permanente Appeals and Resolution Specialist - Rockville Regional Offices in Rockville, Maryland

The Appeals & Resolution Specialist is accountable for: Understanding and applying standards set forth by the National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), Maryland Health Choice Program, State of Virginia Medicaid, State and Federal laws and regulations and Kaiser Permanente Health Plan policies and procedures. Providing expert and timely handling and resolution of all member and provider appeals (i.e. expedited, pre-service and post-service), complaints, grievances and inquiries that are received orally, in writing, and face-to-face. Responding to regulatory inquiries to ensure the Health Plan's compliance with all external requirements and internal service goals. Individuals in this position must possess excellent judgment, critical thinking and problem solving skills. The Appeals & Correspondence Department can be a high stress environment that requires the ability to handle a high volume of diverse work with varying timelines that are driven by regulations. Individuals in this position must have excellent time management/prioritization skills; demonstrated ability to handle multiple tasks, with shifting priorities, while successfully meeting deadlines. This position will be multi-skilled to handle appeals, benefit determinations, complaints, grievances and inquiries for Commercial, Medicare, Medicaid and any new lines of business.

Essential Responsibilities:

  • Participates in managing the region's Appeals & Resolution Process. Accountable for thoroughly investigating all issues, including interviewing the appellant to obtain necessary facts that will assist in resolving the case, collection and documentation of appropriate data and information. Assess plan obligation and potential risk; comply with federal and state laws/regulations, contractual requirements, and accreditation standards; provide contract interpretations and benefit determinations; research and develop case summaries; present cases to the region's Appeals Committee, articulating the appellant's argument and making a recommendation based upon the evidence in the case; negotiate satisfactory resolutions with the Medical Group and Health Plan departments. Collaborate with Patient Financial Services, Membership Administration, Claims and other regional business partners to resolve member complaints/concerns and improve satisfaction and retention; Provide written responses to members, providers and customers on behalf of the Health Plan within established time frames.

  • Ensure integrity of departmental case tracking through thorough, timely and accurate entry, consistent with regulatory protocols and effectively manage case resolution inbox on a daily basis.; Under established guidelines, use sound judgment to waive cost shares in order to resolve the member's case; Partner with Utilization Management, Medical Group, Claims and other departments to ensure all required deliverables are completed in order to close the appeal.

  • Respond to formal inquiries from regulatory agencies, including but not limited to the Maryland Insurance Administration, DC Ombudsman, and Virginia Bureau of Insurance; Work directly with the region's attorneys to provide opinions on legal issues; Analyze, research, initiate action and provide written response to regulators within required timelines. Inform key managers of sensitive inquiries and recommend options/solutions.

  • Participates in departmental meetings, trainings and audits as requested; Escalate issues to management as appropriate to maintain compliance; Demonstrates flexibility with other duties as assigned.

Basic Qualifications:


  • Minimum four (4) years of work experience in customer service, administration, or account management in a healthcare environment required;

  • Minimum two (2) years of experience with NCQA or CMS is required.


  • Bachelor's degree in nursing, health administration, business administration, public health or four (4) years of directly related experience required.

  • High School Diploma or GED

License, Certification, Registration

  • N/A

Additional Requirements:

  • Strong critical thinking, analytical, negotiation, presentation, investigative and problem solving skills.

  • Excellent written and interpersonal communication skills.

  • Knowledge of medical terminology or HMO policy and procedures.

  • Strong customer focus for members and providers.

  • Intermediate proficiency in MS Word and Excel.

Preferred Qualifications:

  • Previous work experience resolving customer complaints or appeals.

  • Experience with Office of Personnel Management (OPM), Maryland Health Choice, Virginia Medicaid or DC regulators.

  • Knowledge of the Health Plan's Products.

  • Claims Adjudication and Processing Experience.

  • Durable Medical Equipment (DME) experience.

  • Coursework in behavioral health.


TITLE: Appeals and Resolution Specialist - Rockville Regional Offices

LOCATION: Rockville, Maryland


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.