Job Summary:Coordinates the organizations responsibility for the complaint and grievance process. Promotes member satisfaction and retention. Advocates for the member by utilizing current customer service strategies and communicating to influence key decision-makers. Processes service issues according to case management standards. Facilitates members interaction with caregivers and administrative staff in order to reduce risk and mitigate professional liability. Interprets data pertaining to members concerns and strategizes with service area physicians and staff to create positive member experiences. Completes the investigation, preparation and presentation of cases for medical and legal review, with emphasis on professional documentation, thorough research and file maintenance. Supports the implementation of new and existing health plan services. This position acts as the functional specialist in such areas as claims and administration for specific, assigned products/services. The Health Plan Service Specialist, particularly at the intermediate level, functions as a member of the management team. Interacts as necessary with Team Managers, Quality Assurance and staff to support the development of the Customer Service Representatives; provides feedback to Team Managers that may be used in corrective action. May provide backup support to Team Managers. May assist CSRs with complicated member issues and inquiries.Essential Responsibilities:
As part of action planning and improving performance capabilities, HPSS is responsible to provide coaching and feedback to the CSRs and work collaboratively with the Team Managers to create a plan of action to improve the overall performance of the CSRs. Utilizing results from side by side observations and assisting with complicated member issues and inquires.
At the direction of their Operations Manager, engage in individual development of CSRs in order to reduce AHT, increase Quality Assurance scores which will improve member satisfaction and member retention. Also acts as a backup for TMs when needed based on the needs of the department.
Responsible for intake and resolution of complaint and grievance cases.
Responds and resolved all escalated issues ensuring first call resolution, responsible for timely intervention of service quality issues and the Department of Managed Health Care inquires/complaints, assists CSRs with complex problems and questions. Accurately document results of assisting CSRs with complicated member issues and inquires.
Subject Matter Expert; Serves as a resource to the MSCC on special projects such as partnering with the MSCC training department to provide feedback and expertise on specialty trainings, facilitation to the staff regarding the LOB they support. It is required that they participate in business meetings along with the Team Manager and Operations Managers to ensure that they have the most recent updated knowledge for their lines of business. They may be called upon to participate in a Service Optimization project to improve performance for their Line of Business.
Support training through delivery of specific modules and post-classroom training support, as needed.
Support User Acceptance Testing (UAT), to ensure successful role out and implementation of new systems to include but not limited to; applications and phone such as HPCHATs and telephony Infrastructure across National sites. This will include pre-implementation and post implementation testing and support, as needed. Travel maybe required.
Support recruitment efforts in conjunction with the Operations Managers in the interviewing and hiring process of Health Plan Service Specialists, as needed.
Compile and manage Customer Satisfaction survey results.
May handle escalated and unresolved calls from less experienced representatives.
Provides guidance to less experienced team members.
Contributes to the design, development and implementation of new programs and service improvements for members, physicians, providers and facility personnel.
Educates providers, staff and members on Health Plan benefits and services.
Accountable for investigation of all issues, including collection and documentation of appropriate data.
Responsible for communicating with members or their authorized representative(s), regarding the Health Plans response and grievance/ complaint process.
Create effective partnerships between Call Center and Member Services at the Medical Center to work collaboratively in responding to and resolving investigative complaints that are received at the call center.
Basic Qualifications:Experience
Minimum four (4) years of experience in a call center in either a health care or customer service field required.
Education
High School Diploma or General Education Development (GED) required.
License, Certification, Registration
N/A
Additional Requirements:
Must have completed the MSCC hew hire training and have passed probation.
Demonstrated proficient knowledge of Call Center policies, practices and systems required.
Computer literacy (including familarity with web technology and MS Office applications).
Must be able to work in a Labor/Management Partnership environment.
Preferred Qualifications:
Minimum four (4) years of related experience in a customer service position in an HMO environment preferred.
Prior MSCC experience desired.
Strong interpersonal and communication skills with emphasis on coaching, developing and facilitation preferred.
Bachelors degree in business/health care administration or related field, OR four (4) years of experience in a directly related field.
Notes:
Shift Mon-Fri 9:30am to 6:30pm
COMPANY: KAISERTITLE: Health Plan Specialist Intermediate - Colorado applicants ONLYLOCATION: Denver, ColoradoREQNUMBER: 1314288External 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.
