Director of Member Services

Job Description

Job DescriptionAbout us:

Solis Health Plans is a new kind of Medicare Advantage Company. We provide solutions that are more transparent, connected, and effective for both our members and providers. Solis was born out of a desire to provide a more personal experience throughout all levels of the healthcare journey. Our team consists of expert individuals that take pride in delivering quality service. We believe in a culture that collaborates and supports one another, and where success is interlinked, and each employee is valued.Please check out our company website at www.solishealthplans.com to learn more about us!

Position is FULLY ONSITE Monday-Friday from 8AM-5PM.

Location: 9250 NW 36th St, Miami, FL 33178.

**BILINGUAL IN ENGLISH AND SPANISH IS REQUIRED**

POSITION STARTING AT $120k, BUT CAN BE HIGHER BASED ON EXPERIENCE!

Full benefits package offered on the first on the month following date of hire including: Medical, Dental, Vision, 401K plan with a 100% company match!

Our company has doubled size, and we have experienced exponential growth in membership from 2,000 members to over 10,000 members!

Join our winning Solis Team!

Position Summary:

The Director of Member Services is responsible for overseeing the day-to-day operations of the Member Services department, ensuring exceptional service delivery to Medicare Advantage members. This role ensures compliance with CMS guidelines, monitors call center performance, audits call quality and manages escalated member issues. The Director works closely with internal departments to improve processes, support team development, and maintain high service standards that promote member satisfaction and operational efficiency.

Essential Duties and Responsibilities:

• Demonstrates a solid understanding of the service operations process’, including all regulatory requirements to ensure department compliance with CMS.
• Assists staff with researching claims, authorizations/referrals, contracts, and medical records reviews to ensure completeness of case work.
• Ensures staff responses to member and provider inquiries, complaints, grievances and appeals in a consistent fashion, adhering to all regulatory, accreditation and internal processing timelines and guidelines.
• Oversees the processing of enrollment and disenrollment elections from Medicare beneficiaries, as well as any other required update to a member record.
• Appropriates communications within all parties, including but not limited to verbal communications and use of approved letters and notices.
• Reviews and/or implements all new CDAG and ODAG requirements.
• Responsible for all Service Operations reporting requirements.
• Implements process improvement.
• If summoned, participates in Administrative Law - Judge Hearings, Judicial Hearings and MAC Hearings.
• Maintains appropriate and up to date knowledge of Service Operation guidelines established by the CMS and working knowledge of Medicare regulations in general.
• Identifies any trends or issues of concern and addresses them with the Service Operations Committee and/or Medicare Compliance Officer.
• Creates and maintains tools, job aids, and training materials to help employees in their efforts to resolve issues and improve their relationship with customers.
• Serves as the key contact for any Medicare outside entity (MAXIMUS Federal Services, ALJ, Judicial Review, MAC).
• Establishes and document processes, policies, procedures and workflows to support compliant and timely handling of enrollments/disenrollments, appeals, grievances, Part D services, member services, and provider services. Create and implement any necessary corrective action plans to bring areas of non-compliance into compliance.
• Develops and manages reporting to monitor key performance indicators, identify trends, conduct root cause analysis, report to appropriate committees, and adhere to regulatory reporting requirements.
• Maintains strong working relations with all internal and external parties.
• Guides all Service Operations team members with any concerns or questions that relate to the Service Operations process.
• Handles escalated calls and assist with the resolution process.
• Assists with reporting, projected planning or process improvement plans.
• Helps monitor the Service Operations and ensure all compliance components are met.
• Uses judgment and informed decision-making to determine appropriate actions on elections and in handling discrepancies.
• Meets with COO on a regular basis to:

1. Provide feedback on departmental and staff issues/opportunities.
2. Staffing requirements and needs.
3. Receive feedback on own performance .

• Reviews overtime report and ensures communication with staff as appropriate.
• Communicates effectively with other professional and support staff in order to achieve positive customer outcomes.
• Promotes and contributes to a positive, problem-solving environment.
• Assists customers, family members and others with concern and empathy; respect their confidentiality and privacy and communicate with them in a courteous and respectful manner.
• Accomplishes call center human resource objectives by recruiting, selecting, orienting, training, assigning, coaching, counseling, and disciplining employees; administering scheduling systems; communicating job expectations; planning, monitoring, appraising, and reviewing job contributions; planning and reviewing compensation actions; enforcing policies and procedures.
• Complies with company policies and procedures and maintains confidentiality of customer medical records in accordance with state and federal laws.
• Ensures compliance with all HIPAA, OSHA, and other federal, state, and local regulations.
• Participates in meetings, training and in-service education, as required.
• Performs other duties as assigned.

Supervisory Responsibility:

Yes

Qualifications and Education:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The qualifications listed below are representative of the knowledge, skills, and/or abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Graduate of an accredited college or university with at least a Bachelor’s degree in Business Administration, Public Health Administration or related field and seven (7) years of managed care experience; or equivalent combination of education and experience.
• Minimum of 5 years experience as a Director in service operations or compliance related to Medicare and/or Medicaid required.
• Prior experience working in a managed care call center environment preferred.
• Minimum of 2 years in a demonstrated leadership or management role required.
• Excellent computer knowledge is required, including proficient knowledge of Microsoft Office.
• Analytical thinker, able to strategize plans based on data and metrics.
• Ability to identify, prioritize and rectify problems systematically.
• Ability to work, learn and implemented approve solutions independently.
• Excellent listening, interpersonal, verbal and written communication skills with individuals at all levels of the organization.
• Must be patient in dealing with an elderly population and sympathetic to hearing or vision deficiencies.
• Ability to work effectively independently and in a team environment.
• Ability to read, analyze, and interpret technical procedures or governmental regulations.
• Ability to write reports, business correspondence, and procedure manuals.
• Ability to effectively present information and respond to questions from groups of managers, clients, customers and the general public.
• Ability to define problems, collect data, establish facts, and draw valid conclusions.
• Must be self-motivated, organized and have excellent prioritization skills.
• Must be able to work well under stressful conditions.
• Must be able to work in a fast paced environment.
• Fluency in Spanish and English required.

What Sets Us Apart:

Join Solis Health Plans as a Director of Member Services and become a catalyst for positive change in the lives of our members. At Solis, you will be part of a locally rooted organization deeply committed to understanding and serving our communities. If you are eager to embark on a purpose-driven career that promises growth and the chance to make a significant impact, we encourage you to explore the opportunities available at Solis Health Plans. Join us and be the difference!