Job Summary:Oversees the daily operations of the local Member Services department responsible for responding to inquiries by health plan members. Supervises staff to ensure adherence to proper member service procedures and service level requirements in accordance to regulatory laws. Investigates causes of member inquiries and complaints.Essential Responsibilities:
Manages the day to day local Member Services operations including face-to-face customer interactions, complaint and grievance processing, and supervision of staff. Facilitates the effective and timely response to member inquiries, the resolution of member complaint and grievance cases. Ensures regulatory requirements and internal departmental standards are met.
Monitors and analyzes causes of member complaints and inquiries. Monitors service levels. Oversees the work product of the staff to ensure the consistent and timely response and handling of member complaints and issues within regulatory requirements.
Recommends, develops and participates in the implementation of action plans aimed at improving service delivery and promote member satisfaction and retention. Recommends goals, objectives, policies and performance standards.
Educates and coaches staff and staff members in assigned local facilities regarding regulatory compliance issues. Coaches a professional staff in identifying, addressing, and resolving select member-provider and member-system conflict in order to prevent professional liability, reduce organizational risk and retain satisfied members.
Identifies, develops and conducts training for staff members and other medical center department members regarding regulatory changes based on a review and analysis of customer contact data and audit trends.
Represents the organization to external clients, including regulatory agencies, employer groups, and potential customers in the resolution of high-profile cases in support of maintaining business partnerships.
Serves as a resource in areas that require customer service expertise. Advises and coaches Medical Center administrative staff members with issues regarding customer service strategies.
Interviews and recommends candidates for employment and termination.
Conducts performance evaluations and salary reviews for assigned staff.
Basic Qualifications:
Experience
Minimum three (3) years of experience in a position requiring extensive, complex problem solving and high-level negotiations involving compliance with regulatory requirements.
Minimum two (2) years of supervisory or team lead experience.
Education
Bachelor degree in business administration, operations research, public health administration, or other related field OR four (4) years of experience in a directly related field.
High School Diploma or General Education Development (GED) required.
License, Certification, Registration
N/A
Additional Requirements:
Demonstrated knowledge of federal and state regulations, laws and accreditation standards related to health care and managed care organizations.
Working knowledge of audit techniques, concets and standards including inter-rater reliability.
Proven skills in conflict resolution and mediation with ability to handle sensitive issues independently and escalate when necessary.
Effective interpersonal as well as verbal and written communication skills.
Demonstrated ability in managing a high-profile and/or large, diverse case load of complex issues preferred.
Demonstrated ability in performing thorough investigations, developing logical conclusions and effective analytical reports.
Must be able to work in a Labor/Management Partnership environment.
Preferred Qualifications:
Experience working with accreditation and regulatory agencies preferred, such as Dept. of Health Services (DHS), Dept. of Corporations (DOC), Health Care Financing Administration (HCFA), National Committee for Quality Assurance (NCQA), and state programs.
Previous experience in supervision and/or experience in training techniques preferred.
Experience in preparing and conducting audits preferred.
COMPANY: KAISERTITLE: Manager Member ServicesLOCATION: Oakland, CaliforniaREQNUMBER: 1268467External 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.