Manager, member services job description

Provides customer support and stellar service to meet the needs of our Molina members and providers.


Resolves issues and addresses needs fairly and effectively, while demonstrating Molina values in their actions. Provides product and service information and identifies opportunities to improve our member and provider experiences.


KNOWLEDGE/SKILLS/ABILITIES



Manages member services operations.
Ensures compliance with state and regulatory requirements.
Identifies new opportunities for process development.
Develops and implements interventions to address deficiencies and negative trends.
Provides exemplary customer service to customers including members, co-workers, vendors, providers, government agencies, business partners, and the general public.
Work with coworkers, management, and other departments to help coordinate problem solving in an effective and timely manner.
Provide technical expertise to co-workers and handles elevated calls
Provide exemplary customer service to customers including members, co-workers, vendors, providers, government agencies, business partners, and general public
Assists agents with questions and escalated calls. Recognizes trends and patterns in call types and engages leadership with suggested solutions.
Achieves individual performance goals as it relates to call center objectives.
Assists with training needs of employees as needed.
Demonstrates personal responsibility and accountability by meeting attendance and schedule adherence expectations.



JOB QUALIFICATIONS


Required Education


Bachelor's Degree or equivalent combination of education and experience


Required Experience


5-7 years


Preferred Education


Graduate Degree or equivalent combination of education and experience


Preferred Experience


7-9 years



To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.


Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.


#PJCC #Li-BeMore

2076-418


General Purpose

Operating within the core values and operating principles of the organization, leads daily operational activities and the processing of member transactions in the Member Service organization. Supervise the processing of complex, and confidential life and annuity insurance transactions. Leads and monitors the work of associates in the Member Service organization to ensure work is systematically organized and accomplished in a timely and accurate manner.

Must be well-organized and focused in order to deliver on strict timelines and meet tight deadlines. Must reflect a strong professional impact with highly effective communication skills. Perform various processing duties to meet the unit's deadlines as required.

Position Responsibilities

Establish and communicate clear expectations to the associates performing duties within the organization in order to meet and exceed Company objectives.

Continually model and promote a positive and favorable Company image. Create an environment that champions a highly engaged workforce.

Schedule work hours, assign job duties and evaluate employee work performance in order to ensure objectives are met. Performance leads staff based on established corporate guidelines.

Responsible for consistently monitoring and coaching Member Service Advocate's calls and provide feedback to ensure desired call quality.

Ensure accurate, timely and efficient processing of unit transactions.

Provide recommendations and act upon process improvement opportunities in a way that increases the efficiencies and effectiveness of the department.

Demonstrate and employ effective project management skills and practices.

Oversee and partner with others to ensure associates are provided the knowledge and resources and training in order to perform the duties of their jobs.

Fully engage in and take ownership of planning and prioritizing short and long-term activities to achieve business objectives.

Participate and take ownership in the selection, hiring, training and development of assigned associates.

Ensure timely and confidential handling of associate records.

Responsible for oversight of the call center technology that enables management to plan for and react to changing business demands.

Perform other duties as assigned.

Core Competencies :

• Achieves Results/Has Bias for Action - Achieves stretch results. Strong bias for action with sense of urgency and high energy. Practices collaborative working environment to achieve more.
• Customer Focus - Has ability to look from customer's view. Viewed as business partner by external and internal customers. Anticipates customer needs to ensure no barriers to doing business.
• Uses Effective Communication Skills - Candid, clear and concise in communication. Effectively matches style, tone and method to audience. Connects with intended audience. Manages communication and feedback within the organization.
• Displays Leadership/Team Orientation - Works collaboratively to achieve organization's success. Optimally uses position and interpersonal skills, mobilizes and encourages others to take action (situational leadership). Willing and able to lead beyond area of expertise.
• Talent Selection & Management - Provides positive coaching. Actively engages staff in ambitious assignments. Holds self and others to high standards. Identifies and hires high potential candidates. Takes action and provides timely and specific feedback to non-performers.
• Technical/Professional Skills - Hold self and others to high standards. Strives to stay ahead of technical/professional expertise to include specific areas of responsibilities. Is proactive and inspires others to stay current in areas of technical expertise.
• Strategic Effectiveness - Demonstrates an organization-wide perspective and creates a shared vision and purpose.
• Business Management - Embrace and model behaviors reflecting sound business principles. Shows initiative in planning and implementing processes that result in defined measurable results.
• PM21

Required Education/Experience

College degree or equivalent experience preferred.

Successful completion of LOMA courses 1, 2, 3 & 4 preferred.

Associate of Customer Service preferred.

Omaha, Nebraska, United States

Full-Time/Regular

PI194443588

The HFHP Case manager is responsible and accountable for providing Quality / No Harm, Customer Experience, and Stewardship by completing a thorough Assessment, Plan of Care development, implementing, monitoring and modifying Plan of Care as needed and determining clinical and financial outcomes. The Case Manager promotes and evaluates the effective utilization of resources using current clinical knowledge, awareness of community resources/services and functioning as a member advocate to ensure optimal case outcomes.
Primary Accountabilities
* Performs reviews to assure members are receiving care in the appropriate setting at the appropriate level.
* Collaborates with members of the healthcare team to facilitate continuity of care, care plans, discharge planning and/or transition of care.
* Collaborates with Medical Director regarding issues of medical necessity, benefit coverage and availability of services.
* Updates authorizations with accuracy and completeness to support accurate claim payments and collaborates with Utilization Management team to assure appropriate care.
* Identify members appropriate for other Health First Health Plans program referrals as well as referrals to community resources/services. Other Health First Health Plan programs to include Inspiris/Care Level Management, Circles of Care, Health Dialog and Disease Management programs.
* Utilizes Health First Health Plan resources in a cost effective manner.
* Document member cost savings based on appropriate utilization of services and evidence based care.
* Identify and document alternative cost saving options for members.

* Current FL RN license required.
* Bachelor's Degree in Nursing preferred plus five years clinical experience.
* Prefer at least two years previous experience to include Utilization Management, Managed Care, and/or Workers Compensation/Disability Medical Management.
* CCM preferred; if not certified, must become a Certified Case Manager within two years of joining the department.
* Knowledge of CPT codes, HEDIS, HIPAA, ICD-9 codes, Medicare Guidelines, and NCQA.
* Knowledge in the following areas:
o Coordination of Benefits including Workers Compensation, Auto Insurance,
o Short and Long Term Disability
o Billing and Claims processing
o Referrals to Ethics Committee, Corporate Compliance, Fraud and Abuse or Legal Services when appropriate
o Reimbursement across the continuum of healthcare
o Alternative treatments options, alternative funding programs and community services and resources.

**Job:** **Case Management*

**Organization:** **HF Administrative Plan Inc*

**Title:** *Case Manager - Health First Health Plan, Member Outpatient Services, Full Time*

**Location:** *Florida - Brevard County-Rockledge*