/RESPONSIBILITIES Directs, supervises, and assists the activities of the Member Services Commercial (EPO / PPO), Health Exchange and CHIP hotlines. Works with departmental leadership to improve any barriers that result in lines of business member’s complaint processes working closely with member service resolution team and member advocates that result in trends and/or other task that the unit is responsible for. Leads, manages and is responsible and knowledgeable for ensuring all aspects of all compliance/regulatory/contractual to include internal/external audits, and accredited agencies are abided.
To include identifying of potential high-risk situations, providing documentation, timely response, and coordination with Community First departments including leading and organizing as needed meetings required to ensure that task is met. for. Ensures that all forms of member inquiries, correspondence, complaints, Initial Concern Complaints, and appeals are acknowledged, investigated, resolved, and responded in accordance with Community First Health Plans (Community First) policies, as well as abide by any accredited, organizations, federal and state regulatory entities.
Ensuring that staff within this unit are current by communicating any changes that occur. Supporting the other units within Member Services as needed and/or as directed by the Directors of Member Services. Responsible and accountable for ensuring that staff are knowledgeable in conjunction with collaborating and updating the department trainer for identifying gaps, refresher training and/or communicating any changes related to these lines of business to include monitoring call center quality outcomes/needs to ensure all regulatory and/or contractually requirements are met.
In addition to conducting analysis/deliverable reports upon request. Consistently supports compliance by maintaining privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to the applicable federal, state, and local laws and regulations, accreditation and licenser requirements (if applicable), and CFHP policies and procedures.
In addition, must be accountable for communication, implementation, enforcement, monitoring and oversight of compliance policies and practices to include the Health Insurance Portability and Accountability Act (HIPAA) related policies in regards to aspects of operations within Member Services. EDUCATION/EXPERIENCE Bachelor’s degree OR a minimum of four years of supervisory work in health care administration, managed care; general health care industry which consists of strong customer service call center, enrollment, and outreach experience is required.
At least 2 years experience developing staff, multiple mainframe systems, ACD Phone Software, and using MS software are required (heavy experience with excel or access is strongly preferred). Ability to speak, read, and write in both English and Spanish is strongly preferred. Preferred Strong experience in call center supervision, training, and being able to develop “Best Practices” talent.
LICENSURE Valid Texas driver’s license is required may need to travel to Community First other office location to assist as needed.