PRINCIPAL RESPONSIBILITIES: Under general direction from the Sr. Director, Member Services, the Member Services Supervisor is responsible for the day-to-day supervision of Member Services Representatives, collaborating with other department Supervisors and other department leadership members to meet and exceed performance targets. The Member Service Supervisor will primarily oversee Member Services Representative Tier I and Member Services Representative Tier II. The Member Service Supervisor is responsible for ensuring member concerns are processed in a timely and accurate manner by communicating and enforcing department goals and objectives within a total quality management approach and compliance with all applicable state/federal regulations. The Member Services Supervisor will be responsible for the quality of the member services representatives daily work and activities, including but not limited to monitoring, developing, implementing, and evaluating the departmental call center operations to ensure optimal proficiency and effectiveness. The Supervisor will oversee assigned production and workflow systems, monitor, and enforce production and quality standards, ensure compliance with all operating policies and procedures, and collaborate with other departments to ensure the Alliances business, operating, and reporting goals are met. The Supervisor may occasionally function as a Member Service Representative in high call volumes or staffing shortages. PRINCIPAL RESPONSIBILITIES INCLUDE:

Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.

Assists the team in carrying out department responsibilities and collaborates with others to support short and long-term goals/priorities for the department.

Oversees the process, management and reporting of the team's activities.

Assists escalated callers as needed.

Works with MS leadership to develop, implement and refine regular reporting metrics to measure productivity and process outcomes.

Implements process improvements as identified and approved by MS leadership.

Works cross functionally to review and revise policies and procedures to ensure National Committee for Quality Assurance (NCQA), Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid Services (CMS) and Department Health Care Services (DHCS) regulatory compliance.

Assists with developing, documenting, and updating regulatory and departmental compliance desktop/SOP policies and procedures.

Builds, maintains and enhances relationships with AAH delegates, vendors, providers, health networks, community-based organizations and other key stakeholders.

Maintains knowledge of current regulatory requirements and industry trends.

Demonstrated knowledge of Medi-Cal benefits, Department of Health Care Services (DHCS) and Department of Managed Health Care (DMHC) regulations.

Superior communication skills and ability to effectively facilitate meetings and delivery.

Supervise the daily operations of Call Center staff to ensure appropriate usage of resources to facilitate the Call Center process.

Identifying the training needs includes assisting in the development of programs, training materials, job aids, orientation checklists, and competency checklists necessary to meet the educational and training needs of departmental staff.

Develop tools and workflows to assist in the training and development of staff

Responsible for maintaining any training materials to align with the current process to provide accurate and consistent plan benefit and service information to our members to meet regulatory requirements.

Develop and conduct team training and education courses, including management education and training for new employees, ongoing staff, and cross-training of staff as needed.

Develop and maintain complex audit processes and audit tools related to griev nces, quality, compliance, and accurate data entry.

Train staff to use audit tools and identify patterns or trends that require additional training or corrective action.

Educate staff as necessary to ensure consistent performance and adherence to standards

Audit staff in accordance with established auditing processes, work with the team to identify and resolve errors in data and reporting, and present findings and recommendations for improvement to management.

Coach and train staff to identify the potential quality of care/service and accessibility concerns and refer to Grievance and Appeals (GandA), Case and Disease Management (CM/DM), Behavioral Health/ABA or Quality Improvement (QI).

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