Position(s) located within the local area Member Services Department reporting to a Member Services Operations Director. Responsible for handling escalated and politically sensitive complaints and grievances that arise in the department and/or the facility in resolving cases within the Medical Center. Responsible for directly supporting quality, training and auditing efforts within the department to help facilitate high levels of quality, service and compliance. Responsible for supporting Case Managers (at the Correspondence Center) in case resolution for difficult members. Participates on work groups/committees and other special projects requiring Member Services expertise and input; represents the Member Services Director as appropriate. Strategizes with 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.
• Compose high quality, detailed written communications.
• Interview anxious and irate individuals and maintain a calm, but alert state of mind; maintain composure under stress, and empathize with individuals regardless of race, creed or economic status.
• Interview and investigate emotional situations with a level of sensitivity and understanding.
• Listen effectively and diffuse angry patients.
• Handle escalated and politically sensitive situations that arise in the department and/or the facility, and assist members with questions and concerns.
• Research, resolve and communicate Health Plan/coverage-related assists for 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.
• Recognize and forward in accordance with regulatory timelines member cases to the appropriate Member Services Department for case processing.
• Perform conflict resolution and mediation with ability to secure action from multiple stakeholders including chiefs, physicians, and administrative leaders.
• 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.
• Support Case Managers (at the Correspondence Center) in case resolution for difficult members including charting a plan of action for frequent flyers with the Medical Department.
• Ensure 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).
• Apply conflict resolution and mediation skills to secure action from multiple stakeholders.
• Responsible for the written and verbal interpretation of the Health Plan service agreement. Educate members/patients about their rights and responsibilities, Medical Center services, policies and procedures.
• Support quality, training and auditing efforts within the department to help facilitate high levels of quality, service and compliance.
• Act as a mentor and resource for Health Plan Representatives/Specialists.
• 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 facility, service area, and regional staff (as necessary) to reach satisfactory service solutions to issues that optimize our members experience with the services they receive.
• Conduct self-audits of work, and assist with departmental audits, to ensure quality and compliance.
• Participate on work groups/committees and other special projects requiring Member Services expertise and input; represent the Member Services Director as appropriate.
• Assist in the design, development and implementation of new program and service improvements for members, providers and facility personnel.
• Effectively utilize service strategies and actively participate in Medical Center service initiatives and activities.
• 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.
• Develop recommendations and processes/service agreements that facilitate Point-Of-Service resolution and/or timely resolution of member/patient grievances and complaints. Assist with daily local Member Services operations and staffing assignments.
• Ensure the integrity of departmental database by thorough, timely and accurate entry, consistent with regulatory protocols and applicable P&Ps. Participate in and/or conduct departmental meetings, trainings and audits as requested. Interpret Health Plan benefits/contracts to internal and external clients.
• 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.
• Perform other duties, as required.

Grade 304

• Minimum five (5) years of customer service experience in the last five (5) years in an environment where customer service, problem solving and compliance with regulatory requirements were the main components of the job.

• High School Diploma or General Education Development (GED) required.

• N/A

• 
  MS Word required, tested at the intermediate level.
• Ability to compose high quality, detailed written communications.
• Strong understanding of health plan terminology and Health Plan contractual interpretation required.
• Ability to handle a high volume of contact with customers, in addition to handling complex cases and escalated member/ patient concerns and issues 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 regardless of race, creed or economic status.
• Ability to interview and investigate emotional situations with a high level of sensitivity and understanding.
• Strong analytical skills and the ability to problem solve creatively, objectively and rapidly.
• Excellent interpersonal/verbal communication skills.
• Ability to prioritize work and ensure that compliance and quality elements are met.
• 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 secure action from multiple stakeholders using conflict resolution and mediation skills.
• Strong project management skills.
• 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.
• Ability to maintain current comprehensive knowledge of Health Plan benefits, eligibility and exclusions.
• May need to travel within the service area to support operations.
• Must be able to work in a Labor/Management Partnership environment.

• Bilingual skills preferred
• Work as a Performance Improvement Advisor preferred.
• Bachelors degree preferred.

PrimaryLocation : California,San Francisco,San Francisco 2350 Geary Medical Offices
HoursPerWeek : 40
Shift : Day
Workdays : Mon, Tue, Wed, Thu, Fri
WorkingHoursStart : 08:30 AM
WorkingHoursEnd : 05:00 PM
Job Schedule : Full-time
Job Type : Standard
Employee Status : Regular
Employee Group/Union Affiliation : A01|SEIU|United Healthworkers
Job Level : Entry Level
Job Category : Customer Services
Department : San Francisco Hospital - Mbr Svc-Member Relations - 0208
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.