Position(s) located within the local area Member Services Department reporting to Member Services Operations Director. Responsible for handling escalated and politically sensitive situations that arise in the department and/or the facility in resolving cases within the Medical Center/medical offices. Responsible for directly supporting quality, training and auditing efforts within the department to help facilitate high levels of quality, service and compliance. Supports Member Case Resolution Center (MCRC) management to effectively resolve member complaints and grievances, per existing Service Level Agreement. Communicates continually with a diverse set of internal and external clientele to achieve excellent results in the areas of complaint and grievance handling, compliance, documentation, benefit/contractual information, and enhancement of the member experience. Educates providers, staff and members on HP benefits, services and applicable regulations. Process End of Next Business Day (ENB) complaints and grievances and acts as a resource to Health Plan Reps regarding ENB case processing. Responsible for partnering with internal and external staff and departments to provide creative, timely solutions for member concerns. Provide guidance to health plan reps in resolving complex, escalated issues with discretion. Assists with oversight of daily local Member Services operations. Participates on work groups/committees and other special projects requiring Member Services expertise and input; represents the Member Services Director as appropriate. Strategize with service area and facility personnel and physicians and acts as liaison between local Member Services and key department designees/ physicians/managers to best assist members/patients in an effective and efficient manner.

• Communicate effectively with members, key service area stake holders, physicians, and staff to identify opportunities to advocate for the member, reduce organizational risk and mitigate professional liability.
• Strong working knowledge of federal and state regulations, laws and accreditation standards related to health care and managed care organizations.
• Develop recommendations and processes/service agreements which facilitate Point-Of-Service resolution and/or timely resolution of member/patient grievances and complaints.
• Act as liaison between local Member Services and key department designees/physicians/ managers to best assist members/patients in an effective and efficient manner.
• Strategize with service area and facility personnel and physicians to create solutions to issues which optimize member experience with care and service.
• In conjunction with local Director, act as liaison to key organizational areas, such as the Member Services Call Center, Health Plan Regulatory Services, Government Relations, and other areas within the Member Services organization.
• Act as operational leader, mentor and resource for Health Plan Representatives/ Specialists.
• Support quality, training and auditing efforts within the department to help facilitate high levels of quality, service and compliance.
• Handle escalated and politically sensitive situations that arise in the department and/or the facility, and assist members with questions and concerns.
• Assist in the design, development and implementation of new program and service improvements for members, providers and facility personnel.
• Support Member Case Resolution center (MCRC) Management to effectively resolve member complaints and grievances per existing Service level Agreement.
• Support medical center management to review and develop plan(s) of action for members who file multiple complaints, in order to promote education and seek appropriate resolution.
• Lead root cause analysis initiatives to delve into member complaints in an effort to eliminate member complaints when possible.
• Attend meetings or conduct presentations to educate providers, staff and individual members on Health Plan benefits and services.
• Participate in managing the organizations complaint and grievance process.
• Responsible for handling escalated communications with members or their authorized representative(s), especially regarding the Health Plans response to grievance/ complaint process.
• Ensure that inquiry and ENB documentation and processing are completed in accordance with regulations, compliance standards and policies and procedures.
• Regulators include, but are not limited to: Center for Medicare/Medicaid (CMS), California Department of Managed Healthcare (DMHC), Department of Health Services (DHS), Department of Labor, Department of Consumer Affairs, the National Committee for Quality Assurance (NCQA).
• Ensure the integrity of departmental database by thorough, timely and accurate entry, consistent with regulatory protocols and applicable policy and procedures.
• Participate in and/or conduct departmental meetings, trainings and audits as requested. Interpret Health Plan benefits/contracts to internal and external clients.
• Educate members/patients about their rights and responsibilities, Medical Center services, policies and procedures Identify member - system conflict, and construct solution recommendations in an effort to prevent professional liability, minimize financial penalties to the organization, and retain satisfied members.
• Communicate continually with a diverse set of internal and external clientele to achieve excellent results in the areas of complaint and grievance handling, compliance, documentation, benefit/contractual information, and enhancement of the member experience.
• Lead efforts to partner with and outreach to internal staff, managers and physicians, to identify opportunities to advocate for the member, and resolve issues as quickly as possible.
• Coordinate efforts between Medical Centers, as appropriate.
• Negotiate with Medical Center, service area, and regional staff (as necessary) to reach satisfactory service solutions to issues that optimize our members experience with the services they receive.
• Effectively utilize service strategies and actively participate in Medical Center service initiatives and activities.
• Assist with oversight of daily local Member Services operations and staffing assignments.
• Participate on work groups/committees and other special projects requiring Member Services expertise and input; represent the Member Services Operation Manager as appropriate.
• Assist non-English or limited-English speaking customers in the use of interpreter services.
• Perform other duties, as required.

• Minimum two (2) years of experience in a customer service position requiring extensive, complex problem solving and negotiation skills, where compliance with regulatory requirements and providing exceptional service to members and patients are the main components of the job.

• Bachelors degree OR four (4) years of experience in a complex HMO or customer service setting.
• High School Diploma or General Education Development (GED) required.

• N/A

• Demonstrated ability to handle a high volume of contact with customers, in addition to handling complex cases and escalated member/patient concerns and issues required.
• Knowledge of and experience with effective customer service strategies required.
• Strong understanding of health plan terminology and Health Plan contractual interpretation required.
• Ability to interview anxious and irate individuals and maintain a calm, but alert state of mind; ability to maintain composure, and ability to empathize with individuals.
• Demonstrated ability to work calmly in a time-sensitive environment involving patients, family members, and advocates.
• Ability to interview and investigate emotional situations with a high level of sensitivity and understanding.
• Demonstrated good analytical skills and the ability to problem solve creatively, objectively and rapidly.
• Knowledge of and experience handling member complaints and grievances required.
• Excellent interpersonal/verbal communication skills.
• Demonstrated ability to compose high quality, detailed written communication.
• Ability to prioritize work and ensure that compliance and quality elements are met.
• Demonstrated conflict resolution and mediation skills with ability to secure action from multiple stakeholders.
• Ability to multitask and manage time in order to perform well on long term projects while being flexible enough to assimilate short term projects on an ongoing basis.
• Ability to assist co-workers and perform effectively in a team environment.
• Ability to serve as a role model: teaching, coaching and providing constructive feedback to colleagues.
• Solid PC skills required (MS Office).
• Must be able to work in a Labor/Management Partnership environment.

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  Preferred Qualifications:
  
  
• Medical Center experience and expertise preferred.
• Customer service training preferred.
• Kaiser Permanente computer systems experience helpful.
• Background in medical terminology preferred.
• Bilingual skills preferred

Note:

• Preferred (Spanish) and will be gauged per QBS standards for proficiency.

PrimaryLocation : California,Irvine,Alton/Sand Canyon Medical Offices II
HoursPerWeek : 40
Shift : Day
Workdays : Mon, Tue, Wed, Thu, Fri
WorkingHoursStart : 08:30 AM
WorkingHoursEnd : 05:30 PM
Job Schedule : Full-time
Job Type : Standard
Employee Status : Regular
Employee Group/Union Affiliation : B01|SEIU|Local 399
Job Level : Individual Contributor
Job Category : Customer Services
Department : OC Lakeview Medical Center - Mbr Svc-Member Relations - 0808
Travel : No
Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.