Ensures adherence to the QUEST Integration(QI)Member Services Program requirements as defined by the State of Hawaii, Department of Human Services (DHS), Med-QUEST Division. Oversees the end-to-end QI member experience across Kaiser Permanente clinical and non-clinical venues. Oversees grievance and appeals operations for all lines of business for the Hawaii Region. Oversees Medicaid grievance and appeals operations across Hawaii and California in a shared service model. Ensures operational and strategic collaboration with the California member services organization across member services functions. Sets the strategic direction, operational vision and implementation of all functions of member services. Builds effective working relationships and collaborates with partners in the Health Plan, Clinics, Hospitals, Permanente Medical Groups, National Member Services functions and Senior Leadership. Continuously focuses on improvements in operational practices inside of Hawaii, across Shared Service operations and internal/external communication. Supervises assigned staff.
- Ensures call center technical capabilities, staffing and training levels support performance requirements.
- Manages/updates/distributes QI Member Handbook content and on-line Member portal content, including the review of all content with DHS.
- Creates and distributes QI ID Cards.
- Ensures the accuracy and completeness of all QI Member Services policies and procedures.
- Provides leadership and direction in the improvement of Hawaii's QUEST Integration administrative platforms.
- Manage the QI Member experience and ensure compliance with MQD contract.
- Ensures adequate staffing and appropriate resources are available.
- Leads Grievance/Appeal processes and protocols.
- Oversees responses to members, physicians, and authorized representatives regarding the Health Plan's response to complaints, grievances and appeals.
- Oversees effectuation of Health Plan's resolution to grievances and appeals.
- Ensures 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 key areas of regulatory focus.
- Provides required regulatory reports.
- Provides recommendations on external environment and internal practices in relation to risk mitigation.
- Provides leadership including budgetary, compliance, service and quality oversight.
Participates in management team committees and tasks forces related to operations.
Participates in regulatory and accreditation agencies' audits and surveys.
Develops, implements and monitors corrective action plans.
Reports unit progress to involved stakeholders.
- Identifies opportunities to improve the efficiency/effectiveness of QI Health Plan functions, collaboration between Regional Health Plan functions and the National Shared Service functions, and customer service. Creates and implements strategy to maximize consumer engagement, communication and the overall customer experience based on feedback from parties inside and outside of immediate functional ownership. Develops and monitors operational and consumer satisfaction metrics in the assessment of existing performance and opportunities for improvement. Monitors performance against QUEST Integration contract requirements.
- Ensures compliance with all regulations and promotes compliance among team members. Ensures functional performance above Regulatory, National and Regional targets. Develops and implements departmental policies and procedures for customer service, membership administration, grievances and appeals.
- Hires, trains, supervises, counsels, disciplines, and terminates assigned staff as appropriate.
- Communicates goals, objectives, accountabilities, priorities, and authority parameters to assigned staff.
- Minimum nine (9) years of business function management in a health care setting, health care administration, medical administration OR equivalent related experience managing large, complex operations functions.
- Minimum three (3) years of management experience.
- Bachelor's degree in business, communications, health care or public administration OR four (4) years experience in a directly related area.
License, Certification, Registration
- Demonstrated experience and skill in strategic planning in a multi-faceted health care or service industry system, leadership, collaborator ability to determine the key business issues and to develop appropriate action plans from multi-disciplinary perspectives, ability to envision, create and implement new program design, project management plans and strategic plans.
- Demonstrated experience and skill in working with senior level managers. Knowledge of the fundamentals and dynamics of business process re-design.
- Demonstrated experience and skill in communication, facilitation, presenting, planning, organizing, problem solving, analysis and attention to detail.
- Call Center management and/or appealsexperience.
- Strategic planning experience in a managed care organization.
- Master's degree in business, communications, health care or public administration, Juris Doctor.
- Knowledge of health plan benefits, contracts and services.
- Knowledge of clinical level activities.
Job Number: 742264