Provides overall management and direction at the medical center for Member Services staff. Oversight responsibility of case processing, and quality of information and services provided by staff to clientele, to minimize the financial liability for the organization, and maximize prudent stewardship of member dues. Ensures contract integrity for the member and for KP. Educates customers, colleagues and community about KP's services and benefits. Builds relationships and collaborates with a variety of internal and external clients to develop strategies, action plans and member-focused systems to support business objectives and the joint vision of KFH/HP and the med group.
Essential Functions:
- Provides leadership (responsibility and oversight/management) for member services at the medical center and medical offices for designated facilities, including budgetary, compliance, service and quality oversight
- Hires, supervises, coaches/trains and develops staff who handle sensitive and multi-faceted member issues and requests
- Creates a team atmosphere and structure that promotes self-directed work through the development and empowerment of staff
- Oversees the daily operations of the member services department, including linkage with auditing, training and analyst work to best meet the needs of staff, members, key stakeholders, and leadership
- Orients and educates facility departments, physicians and other professional staff regarding health plan products, benefits, regulatory guidelines, resolution of member questions, complaints and grievances
- Acts as key liaison with the med group; develops programs and service improvements in conjunction with key med group personnel, managers, and physicians, to improve member experience and resolve member issues as quickly and effectively as possible
- Handles high risk issues by managing timely communication with medical facilities
- Provides ongoing information, reports and recommendations to facility departments and physician chiefs related to data analysis and provision of reports and information related to services and concerns that arise in specific departments
- Fosters a service oriented work environment with an emphasis on dedication to serving members, affording respect to individuals, achievement of highest standards of quality, identifying and supporting opportunities for innovation, supporting teamwork and implementing policies and practices that reflect the vision of KP
- Promotes member satisfaction and retention and influences key decision-makers via use of appropriate service strategies and techniques
- Identifies member-system conflict in an effort to prevent professional liability, minimize financial penalties to the organization, and retain satisfied members
- Communicates effectively with a diverse set of internal and external clientele by consistently utilizing excellent verbal, written, and interpersonal skills
- Negotiates and works collaboratively with facility staff and applicable regional departments to reach satisfactory service solutions to issues that optimize member experience with service
- Oversees compliance/quality/training staff and their work at the local level
- Maintains a current knowledge base regarding regulations and compliance standards, policies and procedures, contract interpretation, service protocols and facility knowledge
- Works directly with, and fosters collaborative working practices between local member services and the correspondence center(s), applicable regional departments, and other departments at the medical center
- Ensures that staff provide timely and thorough responses to members, their physicians, authorized representatives regarding the Health Plan's response to complaints and grievances that are handled at the medical center level
Qualifications:
This is a repost of 146433.
Basic Qualifications:
- Five (5) years of management/leadership experience
- Five (5) years of experience in a complex health care or service organization
- Five (5) years of management/leadership experience in a complex healthcare (preferably HMO) or service-oriented organization
- Significant experience/knowledge working with accreditation and regulatory agencies and/or preparing information for regulatory audits as requested, (including, but not limited to Dept of Health Services (DHS), Department of Managed Healthcare (DMHC), and National Committee for Quality Assurance (NCQA) and Center for Medicare/Medicaid Services (CMS))
- Significant experience in customer service improvement and process redesign, with openness to creative and innovative approaches to providing service, including cultural sensitivity, respect and polite communication with patients and all clientele
- Bachelor's degree or equivalent experience
- Demonstrated management and leadership skills, including working with varied levels of staff, budgeting, delegation, staff development, coaching, resource allocation planning, and performance management
- Demonstrated ability in development of team focus, partnership, service orientation, influence and change leadership
- Demonstrated expertise in results orientation, taking initiative
- Outstanding interpersonal/communication skills with ability to effectively partner with a wide group of stakeholders, including professional and medical staff
- Excellent presentation/public speaking skills and experience
- Demonstrated awareness in emotional intelligence as modeled in day-to day leadership responsibilities
- Ability to use sound judgment and handle potentially charged issues independently and with knowledge and ability to escalate and obtain assistance when needed
- PC Skills/computer literacy (MS Office: Word, Excel, and PowerPoint)
- General working knowledge of Kaiser Permanente Health Plan benefit plans/contracts/systems
- Proven ability and commitment to work collaboratively in a Labor Management Partnership
Preferred Qualifications:
- Preferred master's degree
- Preferred excellent investigation, problem solving
- Documentation skills and demonstrated knowledge regarding Health Care regulation and compliance standards, internal policies and procedures
Notes:
- Collaborates effectively with units in the Member Services Organization, and Health Plan units to ensure compliance with regulatory and accreditation standards, to drive consistency in communication and decision making and to promote and protect the rights and responsibilities of Health Plan members.
- Collaborates with various internal departments to review data, develop reports and identify actionable items related to KP performance in key areas of regulatory focus.
- Provides recommendations on external environment and internal practices to leadership with relation to risk mitigation.
- Participates in management team committees and task forces related to operations, service and other facility, regional or statewide initiatives.
- Actively acknowledges and provides rewards and recognition to staff.
- Manages departmental budget to meet or exceed organizational goals and provide optimal departmental operations.
- Participates in regulatory and accreditation agencies' audits and surveys related to the complaint and grievances Provides reports required by the Health Plan Regulatory Services (HPRS) department to be reported to regulatory agencies.
- Develops, implements and monitors corrective action plans.
- Reports unit progress to involved stakeholders.
- Maintains influencing relationship (set agreement for commitment of deliverables and/or service level ) between the medical center and the medical group administration (MGA).
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.