Assistant Member Services Manager

Job Title:         Tribal Option Assistant Member Services Manager

Job Code:        ASTMSMGR

Department:         Infrastructure Development 

Division:         Tribal Option 

Salary Level:         Exempt 3

Reports To:         Tribal Option Member Services Manager

Last Revised:     September 2021

Primary Function 

The Assistant Member Services Manager will report to the EBCI Tribal Option Member Services Manager of the Cherokee Indian Hospital Authority (CIHA). The Assistant Member Services Manager, under the leadership of the Tribal Option Member Services Manager, and following a matrix team model, will help facilitate, as deemed appropriate, the overall management of the Tribal Options Member Management plan, including participating in the development of the necessary infrastructure and reporting processes to meet the requirements set forth in accordance with the NC Department of Health and Human Services (NC DHHS).

Job Description

The position, as directed via the Member Services Manager, is responsible for: 

•    Assessing member eligibility

•    Enrollment and disenrollment 

•    Member engagement, including but not limited to member surveys, member services website, written and oral member materials, translation and interpretation services, member welcome packet, member handbook, and member grievances. 

•    The position must work collaboratively across all departments to ensure awareness of the goals and expected outcomes detailed in the Member Services plan and develop a process to continuously identify areas for study and improvement, as deemed appropriate. 

Additionally, the Assistant Member Services Manager, under the leadership of the Member Services Manager:

•    Recruits, hires, trains, and measures performance of staff. 

•    May be involved with the design and operations of database systems used to manage member data and produce reports related to program outcomes.

Essential Duties and Responsibilities

Administration, in collaboration with the Tribal Option Member Services Manager:

•    Ensures that the guiding vision, mission and values are incorporated into the development and operations of the Tribal Option’s member management program and division.

•    Provides direct supervision to Member Services staff assigned to the Tribal Option.

•    Develop and implement systems for gathering, managing and reporting Member Services data.

•    Provides education to the community and key stakeholders on the mission and vision of the Tribal Option.

•    Provides leadership, supervision, and professional growth opportunities to direct reports. 

•    Demonstrate knowledge of managed care and healthcare principles: legal, regulatory and confidentiality.

•    Supports all efforts to achieve readiness to obtain national accreditation for health plan management functions, develops, and maintains infrastructure and systems to monitor ongoing member compliance with standards.

•    Prepares reports as required and requested.

•    Ensures member service process is executed in compliance with terms and conditions of DHHS Tribal Option PHP Contract.

•    Examines processes and implements policies and procedures to continually improve upon the operation of the Tribal Option.

•    Ensures appropriate monitoring and oversight of all functions delegated to outside entities.

•    Develops and implements member grievance process in accordance with the NC DHHS PHP contract.

•    Ensures the Tribal Option Director and Tribal Option Quality Management Director is informed of identified quality, health and safety concerns, and trends related to complaints and grievances.

•    On-going monitoring of Member (patient) dashboard and/or report, inclusive of patient alerts.

Fiscal and Business Management

•    Assists with the development of analytic reports to help manage member risk, including over and under-utilization, as deemed appropriate by the Member Services Manager.

•    In coordination with clinical care management, finance management and Member Services Manager, establishes a program that evaluates member and clinical outcomes to ensure quality elements are present in and meet as part alternative payment models that may be implemented under the Tribal Option.

Member Functions

•    In collaboration with EBCI Tribal Option Quality Improvement Management plan conducts annual evaluation of the member plan, as deemed appropriate.

•    Serves as a communication link between members and CIHA-Tribal Option.

•    In collaboration with Quality Management reviews member grievances and complaints and implement action, as needed and deemed appropriate via the Member Services Manager.

•    Solicits member participation in the Tribal Option. 

•    Routinely reviews member accessibility and implements corrective action as needed and deemed appropriate via the Member Services Manager. 

•    Ensures the completion of an annual gap and needs assessment as needed and deemed appropriate via the Member Services Manager.

•    Initiate and develop educational resources to support the needs of the members and/or beneficiaries as needed and deemed appropriate via the Member Services Manager. 

•    Implement an internal review process to ensure accuracy of utilization management decisions, timeliness of decision-making and appropriate notification, as needed and deemed appropriate via the Member Services Manager.

•    Implement a care coordination documentation review process ensuring accurate and timely documentation of care coordination protocol as needed and deemed appropriate via the Member Services Manager. 

•    Ensures accuracy and timely submission of all NC Division of Medical Assistance outlined in Section C of the PHP contract, as needed and deemed appropriate via the Member Services Manager. 

•    Develops policies and procedures related to all aspects of managing consumer grievances and monitors timely response and reports trends and outcomes, as needed and deemed appropriate via the Member Services Manager. 

•    Work cooperatively with the Utilization Management staff, Customer Service, Administration, network providers to effectively resolve patient complaints, as deemed appropriate.

•    Ensures members are informed of all significant changes within the provider network at least 30 days prior to implementation, whenever possible, as deemed appropriate.

•    Establishes mechanisms to identify review and report sentinel (incidents) events for all members covered under the Tribal Option, as needed and deemed appropriate via the Member Services Manager. 

•    Ensure sentinel events/incidents are reported to the state in accordance with state and federal law, as deemed appropriate via the Member Services Manager.

Education/Experience/Minimum Qualifications

•    A Bachelor’s degree in BS/BA required.

•    Minimum five (5) years of recent customer relations management and two (2) years of managed care experience preferred.

•    Knowledge of Medicaid managed care and previous work with tribal health care preferred.

•    Other requirements:

•    Excellent verbal, written and interpersonal skills a must.

•    Excellent analytical and organizational skills with strong attention to details.

•    Proven ability to solve problems and make sound decisions.

•    Ability to work collaboratively with patients, cross-functional agency units and departments.

•    Ability to work independently and within a team environment.

•    Ability to function effectively within an ever-changing environment to meet deadlines and reprioritize as necessary.

•    Proficiency in MS Office and Managed Care tools and platforms.

Supervision Received

The Assistant Member Services Manager reports to the EBCI Tribal Option Member Services Manager. The employee exercises a moderate degree of independence; may consult with the EBCI Tribal Option Member Services Manager, Tribal Option Director, Medical Director and other Directors in resolving issues and maintaining consistency and continuity across agency operations.

Contacts with Others

The personal contacts are with subordinates, co-workers, and higher-ranking managers, leadership of outside entities, patients, and members of the community, as deemed appropriate via the Member Services Manager. The purpose of the contacts is to exchange information, improve care, and resolve differences between subordinates.

Customer Service

Consistently demonstrates superior customer service skills to patients/customers by demonstrating characteristics that align with CIHA’s guiding principles and core values. Ensure excellent customer service is provided to all patients/customers by seeking out opportunities to be of service.