Member Services Manager / Job Req 671415434

PRINCIPAL RESPONSIBILITIES:

Under general guidance of the Senior Director, Member Services, and working in cooperation with other departments, Manager, Member Services is responsible for the oversight of the Member Services Representatives (Level III), MS Outbound Unit and Consultant Supervisor and operations of the Member Services Department. The Manager is knowledgeable of and responsible for compliance and regulatory requirements for the call center. The Manager provides leadership and executes decision-making based on subject matter expertise and judgment. This position is responsible for planning, organizing, and managing all customer service activities and maintaining strong internal and external working relationships. Additional functions of this role are hiring, developing and supervising employees, managing overall task assignment and quality, resolving escalated systems issues, and assisting with Policy and Regulatory requests. The Manager collaborates with other departmental Managers and Directors on all matters as they relate to member services and programs.

Principal responsibilities include:

• Develop and implement Exempt Grievance systems to ensure continued compliance with state and federal regulations;
• Oversee production of Exempt Grievances to ensure successful state/federal audit results;
• Establish workflows and letter templates through collaboration with IT Enrollment; Provider Services; Communication and Outreach and Compliance for member notifications in alignment with regulatory and contractual requirements;
• Design and produce timely call center and exempt grievance reports in compliance with state and federal technical specifications;
• Represent the Alliance as the primary contact for DMHC Help Center and MAXIMUS;
• Provide daily oversight of operations; manage and improve center performance through performance monitoring, system audits and quality assurance measures.
• Provide subject matter expertise to Member Services; Operations; IT Enrollment and Health Care Services management staff to ensure compliance with all regulatory, contractual and accreditation requirements;
• Communicate and collaborate with other departments to establish workflow processes;
• Serve as the primary liaison to resolve complex grievance issues across departments;
• Develop evidence and documents for external audit, to include DMHC/DHCS/NCQA audits, submission to include updated P&Ps, workflows, file universes and source documents;
• Coordinate across the organization to revise operational and reporting processes, as needed;
• Conduct regular exempt grievance audits, analyze results, and recommend corrective action plans (CAP) to address any identified issues;
• Maintain an accurate and complete exempt grievance records in the electronic database;
• Involve and motivate staff to continuously improve and align work processes with department goals and objectives;
• Serve as a primary backup for the Member Services Director by directly overseeing the call center staff to ensure positive morale and effective daily operations;
• Conduct regular staff meetings to address common issues and identify opportunities for process improvement; and
• Evaluate staff and develop corrective action and progressive disciplinary measures, as indicated.

General:

• Monitor program performance to maintain compliance with federal and state regulatory agencies;
• Ensure timely communication with the Director on all/any issues having potential risk and or impact on operations;
• Identify areas of concern and assist in providing feedback to staff and to other departments;
• Report on high risk/high volume members at case conferences, utilization review, and quality improvement meetings;
• Handle escalated member and provider concerns with the dual goal of ensuring satisfaction and retention;
• Make decisions within department guidelines and policies, conduct staff training, and facilitate learning opportunities;
• Assist Director in preparation of department budget and performance reviews;
• Maintain quality management documents, case files, and correspondence in an organized, confidential, and secure manner;
• Participate in creating/revising policies and procedures, and updating call recording QA review scorecards and the call auditing QA program evaluation;
• Maintain databases for tracking and reporting purposes;
• Prepare complete and accurate reports and presentations on call center performance; member satisfaction and mystery shopper scripts;
• Identify trends, patterns, and opportunities for improvement in vendor performance/compliance with service level agreements and communicate findings to Director and other Alliance staff; and
• Complete other duties and special projects as assigned.

ESSENTIAL FUNCTIONS OF THE JOB:

• Ensure select Member Services operations are in regulatory compliance and meet contractual standards;
• Provides leadership and executes decision-making based subject matter expertise and judgment;
• Create and maintain P&Ps and workflows in alignment with regulatory and contractual standards;
• Hire, supervise and train staff;
• Prepare and deliver performance reviews;
• Prepare and deliver performance reports and performance improvement plans as needed;
• Manage and resolve escalated member and provider concerns with the dual goal of ensuring satisfaction and retention;
• Ensure timely communication with Director on all/any issues having potential risk and or impact on operations;
• Maintain documents, case files, and databases in an organized, confidential, and secure manner;
• Oversee preparation of complete and accurate reports and presentations on grievances and appeals;
• Identify trends, patterns, and opportunities for improvement;
• Perform writing, analysis, and report preparation;
• Oversee system maintenance and upgrade implementation. Call for trouble shooting as needed;
• Maintain consistent professional improvement through company provided workshops, tracking call center trends and active participation in team projects; and
• Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

Number of Employees Supervised: 10-12

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

• Bachelor's Degree in Health related field or equivalent work experience required.
• Familiarity with Medicaid (Medi-Cal) and Medicare Managed Care and other publicly funded programs required.

EXPERIENCE:

• Minimum four (4) years job experience in member services for a managed care health plan, or government managed care, or IPA/medical group administration or related healthcare environment.
• Minimum three (3) years of directly supervising a staff of employees in a managed care environment required.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• Excellent written and verbal communication and presentation skills and exercise sound judgment.
• Strong interpersonal, organizational, analytical and problem-solving skills.
• Healthcare experience working with a Medi-Cal HMO plan highly desirable.
• Knowledge of member services call center regulatory compliance standards and reporting responsibilities in a managed care setting.
• Customer service oriented and resourceful.
• Ability to work with others while completing multiple tasks simultaneously and successfully.
• Ability to make decisions in the absence of detailed instructions and work independently or in a team environment.
• Proficient in the use of Microsoft Office products (Word, Excel, Outlook, PowerPoint, and Access).
• Experience in call center phone and CRM solutions (HEALTHsuite, Cisco Finesse (UCCX/CUIC); Calabrio, 2Ring) preferred.
• Bilingual in threshold languages (English/Spanish; English/Cantonese; English/Mandarin; English/Vietnamese; English/Tagalog; English/Arabic) preferred.
• Valid California driver's license, auto registration, and proof of insurance required.
• Must be able to attend meetings/trainings/events both during and after regular work hours, both at or away from the worksite.

SALARY RANGE $105,853.04-$158,779.55 ANNUALLY

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.