Member Services Director

Transcription

1 Central Coast Alliance for Health September 2006 Duty Statement page 1 Member Services Director 1. Responsible for senior management and strategic planning for the Member Services Department, including personnel, fiscal and operational functions, including but not limited to: Developing and directing the implementation of annual and long range goals and objectives for the department within the framework of overall organizational goals and objectives; Developing and maintaining departmental policies and procedures to meet Alliance goals and to ensure regulatory/contractual compliance. Overseeing development, implementation and maintenance of departmental policies and procedures; Designing programs and services, developing workplans and supervising the implementation of programs and services as they relate to Member Services; Coordinating of Member Services functions with other Alliance departments; Conducting policy analysis and preparing proposals (related to Medi-Cal F); Evaluating the needs of the Member Services Department and developing / adjusting strategies and goals accordingly; Evaluating existing systems, programs and designs, and implements modifications as needed (Related to Medi-Cal F); Serving as liaison to Commission committees and advisory groups, as assigned; Preparing and presenting reports for Alliance management and Board as required; Conducting or directing orientation and training of community agencies regarding the Alliance s member services as needed; Developing and implementing marketing activities for Alliance lines of business; Overall management of regulatory and governmental audits and inquiries as they relate to departmental services; Representing the Alliance with local, state and national governmental and community Agencies; Representing the Member Services Department on various company committees as needed; Preparing and monitoring department budget; Supervises Member Services Manager, and Member Services Administrative Assistant; and Hiring, training and supervision of direct reports, and staff. Continued on following page

2 Central Coast Alliance for Health September 2006 Duty Statement page 2 Member Services Director cont d. 2. Responsible for strategic development and implementation of new programs and services as they relate to Member Services including eligibility outreach and enrollment, member satisfaction, new lines of business and special projects, including but not limited to: Researching, proposing and implementing policy changes responsive to the Medi- Cal / Healthy Families / Healthy Kids program(s) and/or the Alliance s business needs, and reviewing proposed policies and implementation plans for value and appropriateness (F); Developing and implementing new programs and services as they relate to Member Services (related to Medi-Cal F); Developing, implementing and managing eligibility outreach and enrollment activities for new programs; and Designing and implementing programs for improving member satisfaction (related to Medi-Cal A). 3. Oversees and provides information to individuals and families about Medi-Cal and directs to Medi-Cal covered services to meet identified needs. (A, B) 4. Works with community and government agencies to identify and fill gaps in health and Medi-Cal services by collaborating and planning for clients and families in need of such services. (F) 5. Collaborates with agency and outside agency staff by engaging in program planning and policy activities to enhance and expand health services, including Medi-Cal services to meet the needs of clients and families. (F) 6. Assists to administer MAA claiming, including development of claim plans and overseeing time survey process. (G)

3 Central Coast Alliance for Health September 2006 Duty Statement page 1 Member Services Manager 1. Responsible for the operations and day to day management of the Member Services Department: Under the direction of the Member Services Director, gives input into departmental goals and objectives and performance metrics and monitors performance during the year; Develops, implements, and maintains departmental policies and procedures; Supervises and provides direction to Member Services Supervisor, Grievance Coordinator, Eligibility Analyst, Billing Specialist, and Department Clerk; Responsible for hiring, training and supervision of direct reports, and staff; Evaluates needs of the Member Services Department; Evaluates existing systems, programs and designs, and implements modifications as needed (related to Medi-Cal F); Participates in management and operations meetings and cross-departmental work groups. Ensures that Alliance members are informed and educated on the procedures, services and benefits of the Health Plan and its impact on their access to care; Responsible for oversight and development of field office locations; Acts as a resource to staff and the Member Services Supervisor in handling difficult and/or complex member situations; Assists with the preparation and monitoring of the department budget; and Serves as liaison to county Department of Social Services and Social Security Administration offices. 2. Responsible for the development and updating of member informing, outreach and marketing materials: Oversees development and dissemination of member literature, including revisions to current Member Handbook, HFP and HKP Evidence of Coverage documents as well as the development of member literature for new lines of business; producing audio and video tapes; developing ID cards, brochures and flyers; and Oversees development and production of the quarterly member newsletter; 3. Responsible for the development and implementation of staff training including HIPAA Level 2 training for Member Services Department staff. Continued on following page

4 Central Coast Alliance for Health September 2006 Duty Statement page 2 Member Services Manager cont d. 4. Manages the Grievance function for the Alliance, with duties including but not limited to: Oversees the Grievance function to ensure compliance with all applicable laws, statutes and regulations; Directing and participating in resolution of member concerns, problems and complaints; Supervising and directing the work of the Grievance Coordinator, including grievance resolution and documentation, statistical analysis and reporting; Attending meetings relating to the Grievance function; Serves as the liaison to the Member Advocate Program vendor; and Does member follow up for provider delete requests. 5. Oversees and provides information to individuals and families about Medi-Cal and directs to Medi-Cal covered services to meet identified needs. (A, B) 6. Works with community and government agencies to identify and fill gaps in health and Medi-Cal services by collaborating and planning for clients and families in need of such services. (F) 7. Collaborates with agency and outside agency staff by engaging in program planning and policy activities to enhance and expand health services, including Medi-Cal services to meet the needs of clients and families. (F)

5 Central Coast Alliance for Health September 2006 Duty Statement page 1 Member Services Representative I/II 1. Provides individual and group orientation and education to potential and current members relating to appropriate utilization of program benefits and services; conducts individual follow-up interviews; assists in selection of Primary Care Physician (PCP); and, makes referrals to other programs and services, as appropriate. (related to Medi- Cal - A, B) 2. Responds to member inquiries regarding eligibility, benefits, procedures, and billing. (benefits A, B, eligibility C) 3. Responds to members concerns and complaints; identifies and assesses problems; and, initiates appropriate action required to resolve the problems at the lowest possible level; and, completes appropriate documentation of problem and resolution. 4. Completes and enters Primary Care Physician Selection forms into the Alliance s data base in accordance with established policies and procedures. 5. Researches member eligibility information, utilizing the Alliance s Management Information System, the State Medi-Cal Eligibility Data System, and the County Case Data System. (Medi-Cal - C) 6. Responds to calls from providers verifying eligibility; and, may provide on-site provider training, as needed. 7. Follows up on referrals from County Eligibility Workers and contacts members or their representatives for orientations, as appropriate. (A, B, C) 8. Coordinates provision of services with Provider Relations and Health Services staff. 9. Attends community meetings and provides Plan information to other agencies, as it relates to Member Services Department and the Alliance. 10. Establishes and maintains effective and cooperative working relations with County Human Resources Agency and Social Security Administration personnel. 11. Assists in training providers office and community agency staff, as directed. (Medi- Cal related A, C) Continued on following page

6 Central Coast Alliance for Health September 2006 Duty Statement page 2 Member Services Representative I/II cont d. 12. Initiates and performs outreach to community, county and other agencies and organizations to develop contacts, provide Plan information, reach members, and network with others. (Medi-Cal related A, B) 13. Issues Alliance ID cards, per established procedures; and provides assistance to members in initiating grievances, when requested, and transmits grievance process materials according to established procedures. 14. Maintains statistical information for weekly and monthly reporting, per established departmental procedures; maintains daily phone/walk-in and pre-natal contact log. 15. Conducts outreach to provide information about services offered by Medi-Cal, and directs clients to application and eligibility staff for eligibility determination. Refers Medi-Cal eligible individuals and families directly to services to meet their needs. (A, B) 16. Assists individuals and families with aspects of the Medi-Cal and Healthy Families/Medi-Cal for Children application process. (C) 17. Arranges transportation for individuals and families, including Medi-Cal enrolled, to Medi-Cal covered health services. (D)

7 Central Coast Alliance for Health September 2006 Duty Statement page 1 Health Programs Coordinator 1. Conducts outreach to and follows up with targeted members through a variety of means as part of the plan s health program activities. Working with clinical staff, coordinates the Post partum, immunization, Weight watchers, and Teen Tune-Up programs including managing database, outreach materials and incentives, and producing reports. (Medi-Cal related A, B) 2. Assists in planning, implementing, and evaluating the Alliance s health programs, with an emphasis on access to care, quality improvement, preventive care, and use of plan and community resources. (Medi-Cal - F) Activities include, but are not limited to: Develops and reviews low cost, low literacy, culturally appropriate educational materials, develops internal materials and activities; Develops and produces informational mailings to members and/or providers (Medi-Cal A); Publicizes available resource information (Medi-Cal A); Assists in maintaining health information at provider offices (Medi-Cal A); Under the supervision of the Health Programs Manager, researches, compiles information and develops submissions for grant applications as necessary. Creates and maintains relationships with funders; and Contributes to development and improvement of Alliance website as assigned. 3. Plans, organizes and implements health programs interventions and outreach activities in coordination with other Alliance staff, departments, and outside agencies as appropriate, including: Upon referral by Member Services or other sources, provides guidance to members in the proper use of health services and assistance in accessing health education services and other community resources; Works with local health coalitions on outreach activities to target member groups, as appropriate; Works with Alliance staff and local community agencies to make presentations, as appropriate; Plans and conducts education sessions with providers, as appropriate. (Medi-Cal related A, B) 4. Acts as liaison with the community and other agencies, including: Establishes effective working relations and professional contacts with service agencies and community resources; Identifies existing health problems of Medi-Cal population and develops referrals to and coordinates with existing community resources and programs, or assists in development of new programs. (Medi-Cal related A, B, F) 5. Acts as language and cultural liaison in support of Alliance Staff and Members. Translation and creation of documents into Spanish for all agency departments and community collaboratives. Spanish language assistance with complex Case Management situations as appropriate. Continued on following page

8 Central Coast Alliance for Health September 2006 Duty Statement page 2 Health Programs Coordinator cont d. 6. Performs general administrative duties including maintaining appropriate records and files of health program activities and correspondence. 7. Conducts outreach to provide information about services offered by Medi-Cal, and directs clients to application and eligibility staff for eligibility determination. Refers Medi-Cal eligible individuals and families directly to services to meet their needs. (A, B) 8. Assists individuals and families with aspects of the Medi-Cal and Healthy Families/Medi-Cal for Children application process. (C) 9. Arranges transportation for individuals and families, including Medi-Cal enrolled, to Medi-Cal covered health services. (D) 10. Collaborates with agency and outside agency staff by engaging in program planning and policy activities to enhance and expand health services, including Medi-Cal services to meet the needs of clients and families. (F)

9 Central Coast Alliance for Health September 2006 Duty Statement page 1 Healthy Kids Enrollment Coordinator 1. Determine eligibility of applicants to the Healthy Kids Program according to eligibility criteria and plan guidelines. (Medi-Cal related C) Receive and log enrollment applications; Review applications for completeness and refer any issues to Certified Application Assistors (CAAs) for resolution; Enter information from application into Alliance eligibility system and determine eligibility of applicants using Healthy Kids eligibility criteria, screening for Medi- Cal/Healthy Families eligibility and checking MEDS to ensure that applicants are not already on Medi-Cal or Healthy Families; Respond to applicant inquiries about the eligibility determination process and refer applicants to CAAs Generate correspondence to applicants for denials; Refer applicants to CAA for redirect to Medi-Cal or Healthy Families when applicable; and Receive, document and refer eligibility determination appeals to Grievance Coordinator. 2. Initiate and complete annual redeterminations. (Medi-Cal related C) Run reports of members due for annual redetermination and generate appropriate forms and correspondence; Follow up, if annual renewal forms are not returned or are incomplete, and send notice of termination as appropriate; Review completed renewal forms and redetermine member eligibility for another year; and Collect and forward premium payments. 3. Enroll new members. Enter data for newly eligible Healthy Kids members into Alliance Healthy Kids database and assign PCP if one is designated on the application; and Provide report of new members to Member Services Representatives for new member orientation and PCP linkage. Continued on following page

10 Central Coast Alliance for Health September 2006 Duty Statement page 2 Healthy Kids Enrollment Coordinator cont d. 4. Collect and track initial premium payments and coordinate with Billing Representative to work with members at risk of disenrollment for non-payment of premiums. Coordinate with Finance Department Billing Representative to forward initial premium payment for posting and deposit; Determine eligibility of potential applicant for sponsorship program, based on CAAs recommendation, sponsorship criteria and availability of funds; Provide enrollment data to support Alliance invoicing of Healthy Kids premium funds; and Receive data from Billing Representative on members at risk of disenrollment due to non-payment of premiums and generate appropriate correspondence and/or make calls to follow-up. 5. Perform, track and report on member disenrollment. 6. Disenroll members as appropriate according to Healthy Kids eligibility criteria and disenrollment guidelines, including generating appropriate correspondence to the applicant and making changes to the Alliance member database; and Maintain database of members who have been disenrolled due to non-payment of premiums, who are prevented from disenrolling for 3 months. (Medi-Cal related C) 7. Organize, analyze and report on program and member data including enrollment statistics, denied applications, disenrollment statistics, and use of sponsorship program and redetermination statistics. 8. Perform application assistance and participate in outreach events. (Medi-Cal related A, B, C) 9. Conducts outreach to provide information about services offered by Medi-Cal, and directs clients to application and eligibility staff for eligibility determination. Refers Medi-Cal eligible individuals and families directly to services to meet their needs. (A, B) 10. Assists individuals and families with aspects of the Medi-Cal and Healthy Families/Medi-Cal for Children application process. (C) 11. Arranges transportation for individuals and families, including Medi-Cal enrolled, to Medi-Cal covered health services. (D)

11 Central Coast Alliance for Health September 2006 Duty Statement page 1 Provider Services Analyst 1. Responsible for maintaining provider data related to contracts and payment policies, with duties including but not limited to: Monitoring and documenting the numerous contract types and amendment numbers for all providers; Entering all credentialing information before each PRCC meeting into Caradigm for all providers being credentialed or re-credentialed. Reporting using Discoverer to ensure accuracy of provider and payment data in Caradigm. Assist with interpretation of provider contracts; Ensure accuracy of provider data in Diamond, Caradigm, and other databases used by the Alliance; Development of work plan and timeline for completeness; Creating and revising policies and procedures related to adding or changing provider data in the Alliance computer system; Attends OILs meetings and Monitors Policy Letters and Operating Instruction Letters from DHS and determines impact to provider contracts and/or provider data as necessary; Assists in development and implementation of provider contractual provisions based on legislative and/or Board directives; Notifies appropriate Alliance staff/departments regarding implementation of new contract rates and/or terms; Provides technical and analytical support relevant to provider contracting functions to internal and external customers as needed. Maintains and assigns responsibility to department task list in Outlook Public Folders to track all Provider Educations, ZX, AT and P98 Pends. Follows up with all departments submitting provider inquiry forms. 2. Responsible for the coordination of interim and annual risk settlement activities as they relate to verification of contract status, IPA risk groups, and consistency with contracts, with duties including but not limited to. Researches and responds to inquiries from Finance Department; Maintains tracking list for Finance for all tasks submitted by provider services reps. Maintains accuracy of risk group affiliation in Alliance computer system; Assists in the development of risk settlement materials to be shared with providers to provide explanation of results, including letters, visual documents, bulletins, etc. Continued on following page

12 Central Coast Alliance for Health September 2006 Duty Statement page 2 Provider Services Analyst cont d. 3. Responsible for auditing 10% of the credentialing files after each PRCC meeting and maintaining a spreadsheet to track credentialed providers and findings of audit. 4. Conducts outreach to provide information about services offered by Medi-Cal, and directs clients to application and eligibility staff for eligibility determination. Refers Medi-Cal eligible individuals and families directly to services to meet their needs. (A, B) 5. Assists individuals and families with aspects of the Medi-Cal and Healthy Families/Medi-Cal for Children application process. (C)

13 Central Coast Alliance for Health September 2006 Duty Statement page 1 Administrative Assistant 1. Perform a variety of general business office duties such as setting up files, distributing mail and faxes, composing correspondence, follow-up, setting up tracking procedures, filing, preparing new member packets and processing provider selection forms; Assist in the development of member informing and outreach/marketing materials such as the Member Handbook, Evidence of Coverage documents, open enrollment materials, member ID cards, brochures and flyers; Coordinate annual revisions to the Member Handbook/Evidence of Coverage documents; Coordinate translation and printing of member informing and outreach/marketing materials and documents; Maintain form, letter and correspondence files for Department management staff; Develop and maintain consistency in style, appearance and message of Member Services external documents, including committee materials, annual reports, and workshop materials; and Assist with development of organizational standards for printed materials, and methods to train staff on implementation and maintenance of standards. 2. Perform all functions as administrative staff support to the Member Services Advisory Groups, and other committees as assigned: Take and transcribe minutes, maintain all committee records; Prepare and coordinate agenda packets; prepare and record all committee resolutions for Alliance MSAG meetings; Schedule and coordinate meeting places and times for all committee meetings; Maintain Member Services Policy and Procedure Manual and other Administrative documents (Grievance, HIPAA Privacy, etc); Compile, prepare and maintain regulatory applications, documents, and compliance materials; Establish and maintain central Member Services files and indexing system; Prepare and update training and resource materials for new staff. Open and distribute mail for department as required. Continued on following page

14 Central Coast Alliance for Health September 2006 Duty Statement page 2 Administrative Assistant 3. Answer, direct and place telephone calls, schedule conference calls for Member Services Manager and Supervisor and other designated staff; Plan, coordinate and schedule travel arrangements and meetings as required; Schedule meetings and appointments, and maintain conference rooms meeting schedules; Compose correspondence, perform general research, and prepare reports as directed; Use computer in preparation of letters and other documents from longhand and dictation; Format spreadsheets on personal computer, track and enters data, prepare monthly statistical reports for both internal and external use; Develop and maintain reports on departmental performance metrics Prepare materials for publications and presentations; Coordinate quarterly member newsletter development and publication Assist with presentations such as open enrollment meetings Perform back-up eligibility verification for lunch breaks and as required for absences (Medi-Cal C) 4. Develop and maintain master file of Member Services printed materials to ensure consistency with standards. Assist in coordination and preparation of materials for audits by regulatory bodies including but not limited to the California Department of Health Services (DHS) and the Department of Managed Health Care (DMHC). 5. Serve as backup for reception when needed. 6. Conducts outreach to provide information about services offered by Medi-Cal, and directs clients to application and eligibility staff for eligibility determination. Refers Medi-Cal eligible individuals and families directly to services to meet their needs. (A, B) 7. Assists individuals and families with aspects of the Medi-Cal and Healthy Families/Medi-Cal for Children application process. (C) 8. Arranges transportation for individuals and families, including Medi-Cal enrolled, to Medi-Cal covered health services. (D)

15 Central Coast Alliance for Health September 2007 Duty Statement page 1 Business Development Director 1. Identify, evaluate and recommend strategic business development opportunities. Conduct analyses to identify opportunities to expand and diversify Alliance services. Organize and conduct analyses of market demand, risks, financial feasibility, operating requirements and budgets, and regulatory requirements as directed. Present evaluations and recommendations to staff, board and community as needed. 2. Develop new business opportunities. Assist with developing conceptual and detailed design plans for new lines of business. Develop work plans to implement new lines of business, in collaboration with management and business partners. Monitor and facilitate progress on implementation of new lines of business, including leading on interdepartmental project teams. Lead and/or collaborate in grant acquisition and project management. 3. Improve administrative quality and performance. Conduct analyses to identify opportunities to improve quality and performance in current lines of Alliance business, and make recommendations. Evaluate Alliance s management reports and make recommendations for improvement. Monitor and facilitate progress on improvements of Alliance s current lines of business. Monitor and facilitate progress on improvements to Alliance business, including leading interdepartmental project teams. 4. Assure regulatory compliance. Coordinate with Government Relations Director in identifying and communicating regulatory requirements and standards for the health plan. Supervise Compliance Manager to ensure compliance with contractual, regulatory and statutory requirements governing the health plan, and successful operation of the plan s Compliance Program. Continued on following page

16 Central Coast Alliance for Health September 2007 Duty Statement page 2 Business Development Director cont d. 5. Conduct marketing and public relations. Develop and conduct marketing plans for new and current lines of business. Assist Executive Director with public relations activities to promote the Alliance. Direct media relations, including press releases, media alerts, proofing stories to the media, and building relationships with media companies. Oversee design, development and maintenance of the Alliance s marketing materials and communication tools, including the Alliance s website content, marketing materials and promotional tools. 6. Conduct Health Planning. Works with community and government agencies to identify and fill gaps in health and Medi-Cal services by collaborating and planning for clients and families in need of such services. (F) Collaborates with agency and outside agency staff by engaging in program planning and policy development activities to enhance and expand health services, including Medi-Cal services to meet client and family needs. (F)

17 Central Coast Alliance for Health September 2007 Duty Statement CCS Case Manager 1. Provides case management and outreach support to the utilization review process. Interprets benefits based on the benefit language as outlined in Title 22 and The Alliance policies and Procedures for all lines of business. Performs case management on cases which meet the Alliance s case managed criteria or as referred by providers or designated Alliance staff. Ensures confidentiality of utilization review and quality assurance information, and individual beneficiary identification. Provides liaison with California Children s Services (CCS) for initial determination of CCS referral. Assists with data collection for special member determination. Assists with review of medical records to determine benefit coverage, health care needs for continuity of care and potential referral to CCS. Conducts outreach to high risk, high need populations to provide information about services offered by Medi-Cal, and directs clients to application and eligibility staff for eligibility determination. Refers Medi-Cal eligible individuals and families directly to provider services. (A, B) Arranges transportation for, and if necessary, accompanies individuals and families, including Medi-Cal enrolled, to Medi-Cal covered health services to meet identified needs. (D) 2. Provides assistance to acute and long-term care discharge planning process and oversight of member access to appropriate care. Updates and processes forms for member files. Performs on-site review of medical records, as needed. Works closely with contracting and attending physicians, county social services, department and institutional staff to assist with identification of members needing case management services, discharge planning and coordination of care. Establishes and maintains effective working relationships with community resources and services agencies. 3. Performs additional Alliance case management related work duties. Prepares written reports of Alliance utilization information, including summary of case management functions and updates of case status, use of covered services and other pertinent performance data, as directed. Supports data entry function as needed.

18 Central Coast Alliance for Health September 2007 Duty Statement Children s Case Manager 1. Works with family members to identify and evaluate services options for special needs children. Serves as liaison between the Health Plan and San Andreas Regional Center (SARC) to identify Alliance children enrolled in SARC programs to promote effective collaboration in the coordination of care. Serve as liaison between Health Plan, school districts and primary care providers to maximize continuity of care. (Medi-Cal related outreach, access assistance A, B) Facilitates collaboration and appropriate exchange of information between Health Plan, the Early Start/Early Intervention programs and primary care providers to promote continuity of care to Alliance special needs children. (Medi-Cal related outreach, access assistance A, B) Assists providers with referrals to Early Start/Early Intervention Special Education Local Plan Area (SELPA) programs. 2. Works with other agencies serving special needs children including, but not limited to: CHDP, Children s Mental He3alth and Foster Care agencies to promote and ensure access to available medical and social services. Conducts outreach to high risk, high need populations to provide information about services offered by Medi-Cal, and directs clients to application and eligibility staff for eligibility determination. Refers Medi-Cal eligible individuals and families directly to provider services. (A, B) Arranges transportation for, and if necessary, accompanies individuals and families, including Medi-Cal enrolled, to Medi-Cal covered health services to meet identified needs. (D) 3. Works with and educates providers as to importance of enrollment in Early Start/Early Intervention Special Education Local Plan Area programs for children meeting criteria. 4. Interfaces with Health Plan Utilization Management staff to identify and promote resolution of quality issues pertaining to special needs children. Collaborates with Alliance staff to maximize care and prevent duplication of services, resolve issues, etc. Participates in Quality Improvement Programs pertaining to children. Consults with hospital discharge planners to identify best placement options post-hospitalization. Interprets benefits based on Title 22 and plan policies to assess appropriate levels of care. Attends committee meetings as needed.

19 Central Coast Alliance for Health September 2007 Duty Statement page 1 Health Programs Manager 1. Oversees the design, implementation and evaluation of health programs and disease management programs. Manages and coordinates health promotion and chronic disease management programs within the Health Plan. (Medi-Cal related outreach A, B) Develops and implements health promotion and disease management programs to meet the needs of members in multiple lines of business. Measures, trends and evaluates efficacy of health promotion and disease management program on an annual basis. (Medi-Cal related planning F) Identifies care needs within member population through practice profiles. (Medi-Cal related planning F) Investigates potential project areas and recommends appropriate intervention. Collaborates with internal staff, including Health Services Manager, to identify at-risk members. Collaborates with providers and other external customers to develop interventions for high-risk members. Prepares health and disease management program promotional materials, including newsletter articles, pamphlets and brochures. Coordinates activities with local, State and federal agencies, including public relation activities for Health Programs staff. Recommends Health Programs changes and modifications. (Medi-Cal related planning F) Maintain current knowledge of regulatory requirements pertinent to Medi-Cal, Healthy Families and other lines of business. Oversees and conducts outreach to high risk, high need populations to provide information about services offered by Medi-Cal, and directs clients to application and eligibility staff for eligibility determination. Refers Medi-Cal eligible individuals and families directly to provider services. (A, B) 2. Supervises Case and Disease Manager, Medical Social Workers and Health Program Coordinators. Manages and coordinates daily activities of Health program staff. Supervises Case Managers and Disease Managers including Medical Social Worker Disabilities Liaisons. Supervises staff in initiating case management activities. Hires, trains, and coaches staff, including orienting new staff. Continued on following page

20 Central Coast Alliance for Health September 2007 Duty Statement page 2 Health Programs Manager cont d. 3. Develops and maintains collaborative partnerships with various levels of internal and external customers. Participates in regional and statewide collaborative workgroups to develop strategies for effective health/disease management. (Medi-Cal related planning F) Identifies grant opportunities and develops grant applications to support regional health programs management, including monitoring grant budgets and expenditures and supporting and promoting in-house programs. Identifies and coordinates potential funding for continuing medical education (CME) programs. Maintains interagency relationships with County Health Services Agency and other community organizations. Works with community and government agencies to identify and fill gaps in health and Medi-Cal services by collaborating and planning for clients and families in need of such services. (F) 4. Participates in quality improvement and administrative projects, including: annual HEDIS studies; Quality Improvement Projects; preparation of DHCS/DMHC Audits and Investigation audits; annual budgetary process; Development of departmental policies and procedures; and preparation of reports for presentation to internal staff and external audiences.

21 Central Coast Alliance for Health September 2007 Duty Statement page 1 Health Programs & Translation Coordinator 1. Conducts outreach to and follows up with targeted members through a variety of means as part of the Health Plan s health program activities. (Medi-Val related outreach A, B) 2. Working with clinical staff, coordinates the post-partum, immunization, weight watchers, and Teen Tune-Up programs including managing database, outreach materials and incentives, and producing reports. 3. Acts as language and cultural liaison in support of Alliance staff and Members. Translates and creates documents into Spanish for all agency departments and community collaboratives. Provides Spanish language assistance with complex case management situations as appropriate. Serves as the Translation Team Coordinator. 4. Assists in planning, implementing, and evaluating the Alliance s health programs, with an emphasis on access to care, quality improvement, preventative care, and use of plan and community resources. Develops and reviews low cost, low literacy, culturally appropriate educational materials, develops internal materials and activities. Develops and produces informational mailings to members and/or providers. (MC related outreach A, B) Publicizes available resources information. (MC related outreach A, B) Assists in maintaining health information at provider offices. (MC related outreach A, B) Under the supervision of the Health Programs Manager, researches, compiles information and develops submissions for grant applications as necessary. Creates and maintains relationships with funders. Contributes to the development and improvement of Alliance website as assigned. 5. Plans, organizes and implements health programs interventions and outreach activities in coordination with other Alliance staff, departments, and outside agencies as appropriate. Works with local health coalitions on outreach activities to target member groups as appropriate. (MC related outreach A, B) Works with Alliance staff and local community agencies to make presentations, as appropriate. Plans and conducts education sessions with providers, as appropriate. Continued on following page

22 Central Coast Alliance for Health September 2007 Duty Statement page 2 Health Programs & Translation Coordinator cont d. 6. Acts as liaison with community and other agencies. Establishes effective working relations and professional contacts with service agencies and community resources. Identifies existing health problems of Medi-Cal population and develops referrals to and coordinates with existing community resources and programs, or assists in the development of new programs. (MC related outreach, access assistance A, B) Arranges transportation for, and if necessary, accompanies individuals and families, including Medi-Cal enrolled, to Medi-Cal covered health services to meet identified needs. (D) 7. Performs general administrative duties including maintaining appropriate records and files of health program activities and correspondence.

23 Central Coast Alliance for Health September 2007 Duty Statement page 1 Medical Social Worker 1. Coordinates case management services to members. Consults with attending and consulting physicians, County Social Services, departmental and institutional staff to identify members needing case management services and coordination of care, and refer members to appropriate agencies. (Medi-Cal related outreach, referral A, B) Accepts referrals and makes recommendations to appropriate agencies and assess available levels of care in order to successfully coordinate services. (Medi-Cal related outreach, access assistance A, B) In conjunction with Utilization Review (UR) Nurses, facilitates pre- and postdischarge planning for members from acute hospitalization and/or skilled nursing facility placements; and accesses available resources from community and County agencies. (Medi-Cal related outreach, access assistance A, B) Identifies and screens members eligible for Special Member status; and, in conjunction with the Medical Director, applies criteria for Special Member status. Performs home visits to members in order to screen for safety, assess in-home needs, accessibility to other community/county resources. Maintains documentation of case management plans/interventions and statistics required to demonstrate the cost effectiveness of case management and the impact on member s health care outcomes. When needed, develops a plan with multidisciplinary collaboration which identifies goals and options for members with special needs. Provides ongoing evaluation of the member s progress, effectiveness of the service plan, as well as the efficacy and appropriateness of the services provided. Advocates on member s behalf to ensure quality of care and attainment of appropriate goals. Conducts outreach to high risk, high need populations to provide information about services offered by Medi-Cal, and directs clients to application and eligibility staff for eligibility determination. Refers Medi-Cal eligible individuals and families directly to provider services. (A, B) Arranges transportation for, and if necessary, accompanies individuals and families, including Medi-Cal enrolled, to Medi-Cal covered health services to meet identified needs. (D) Continued on following page

24 Central Coast Alliance for Health September 2007 Duty Statement page 2 Medical Social Worker cont d. 2. Establishes and maintains ongoing working relationships with other community agencies. Serves as liaison with other agencies including California Children s services (CCS), San Andreas Regional Center (SARC) and County Mental health. Represent the Alliance ay community meetings and confidential multidisciplinary task forces concerning health issues of provision of health related services. Assesses for changing social needs within the community. Monitors and maintains current knowledge of legislative and regulatory changes that affect members. Works in conjunction with the Health Educator to enhance community resources available to Alliance members. 3. Participates in Quality Improvements activities. Participates in quality improvement studies required by DHCS, CMS and other agencies. Participates in regular internal quality review team proceedings Initiates case conferences as needed; attends daily UR case conferences as directed by the Health Services Manager. Assists the Member Services Department with case management issues regarding members involved in difficult situations. Interfaces with other Alliance departments as required to support service delivery including MIS, Claims and Finance in order to assist with systems planning.

25 Central Coast Alliance for Health September 2007 Duty Statement Utilization Review Nurse 1. Performs preauthorization, concurrent and retrospective review for all hospital/snf/hospice and other LTC facilities utilizing the established criteria/protocols as approved by the plan. 2. Performs preauthorization review for all services, both in an outpatient, based on the Medi-Cal TAR list or the Plan TAR list utilizing criteria/protocols as established by the plan. 3. Interprets benefits based on the benefit language as outlined in Title 22, Provider Manual, and plan policies and procedures, to evaluate appropriate care for all lines of business. 4. Reviews medical records to determine benefit coverage including appropriateness and level of care. 5. Updates and processes forms for member/provider files. 6. Assists Member Services, Claims and Provider Services departments with issues that require medical interpretation of definition. 7. Performs audits of medical records as needed. 8. Works closely with attending and contracting physicians, ancillary providers, county services and institutional staff to facilitate discharge planning. 9. Protects confidentiality of utilization review, quality management information and beneficiary identification. 10. Prepares written reports on the Alliance utilization information, including admissions, discharges, authorization denials, use of covered services and other pertinent performance data, as directed. 11. Conducts outreach to high risk, high need populations to provide information about services offered by Medi-Cal, and directs clients to application and eligibility staff for eligibility determination. Refers Medi-Cal eligible individuals and families directly to provider services. (A, B)

26 Central California Alliance for Health July 2009 Duty Statement page 1 Member Services Director 1. Responsible for senior management and strategic planning for the Member Services Department, including personnel, fiscal and operational functions, including but not limited to: Developing and directing the implementation of annual and long range goals and objectives for the department within the framework of overall organizational goals and objectives; Developing and maintaining departmental policies and procedures to meet Alliance goals and to ensure regulatory/contractual compliance. Overseeing development, implementation and maintenance of departmental policies and procedures; Designing programs and services, developing workplans and supervising the implementation of programs and services as they relate to Member Services; Coordinating of Member Services functions with other Alliance departments; Conducting policy analysis and preparing proposals (Medi-Cal planning activities will be coded to F); Evaluating the needs of the Member Services Department and developing / adjusting strategies and goals accordingly; Evaluating existing systems, programs and designs, and implements modifications as needed (Medi-Cal planning activities will be coded to F); Serving as liaison to Commission committees and advisory groups, as assigned; Preparing and presenting reports for Alliance management and Board as required; Conducting or directing orientation and training of community agencies regarding the Alliance s member services as needed; Developing and implementing marketing activities for Alliance lines of business; Overall management of regulatory and governmental audits and inquiries as they relate to departmental services; Representing the Alliance with local, state and national governmental and community Agencies; Representing the Member Services Department on various company committees as needed; Preparing and monitoring department budget; Supervises Member Services Manager, and Member Services Administrative Assistant; and Hiring, training and supervision of direct reports, and staff. Continued on following page

27 Central California Alliance for Health July 2009 Duty Statement page 2 Member Services Director cont d. 2. Responsible for strategic development and implementation of new programs and services as they relate to Member Services including eligibility outreach and enrollment, member satisfaction, new lines of business and special projects, including but not limited to: Researching, proposing and implementing policy changes responsive to the Medi- Cal / Healthy Families / Healthy Kids program(s) and/or the Alliance s business needs, and reviewing proposed policies and implementation plans for value and appropriateness (Medi-Cal planning activities will be coded to F); Developing and implementing new programs and services as they relate to Member Services; Developing, implementing and managing eligibility outreach and enrollment activities for new programs; and Designing and implementing programs for improving member satisfaction (Medi-Cal outreach activities will be coded to A). 3. Oversees and provides information to individuals and families about Medi-Cal and directs to Medi-Cal covered services to meet identified needs. (A, B) 4. Works with community and government agencies to identify and fill gaps in health and Medi-Cal services by collaborating and planning for clients and families in need of such services. (F) 5. Collaborates with agency and outside agency staff by engaging in program planning and policy activities to enhance and expand health services, including Medi-Cal services to meet the needs of clients and families. (F) 6. Assists to administer MAA claiming, including development of claim plans and overseeing time survey process. (G)

28 Central California Alliance for Health July 2009 Duty Statement page 1 Member Services Manager 1. Responsible for the operations and day to day management of the Member Services Department: Under the direction of the Member Services Director, gives input into departmental goals and objectives and performance metrics and monitors performance during the year; Develops, implements, and maintains departmental policies and procedures; Supervises and provides direction to Member Services Supervisor, Grievance Coordinator, Eligibility Analyst, Billing Specialist, and Department Clerk; Responsible for hiring, training and supervision of direct reports, and staff; Evaluates needs of the Member Services Department; Evaluates existing Medi-Cal systems, programs and designs, and implements modifications as needed (Medi-Cal planning activities will be coded to F); Participates in management and operations meetings and cross-departmental work groups. Ensures that Alliance members are informed and educated on the procedures, services and benefits of the Health Plan and its impact on their access to care; Responsible for oversight and development of field office locations; Acts as a resource to staff and the Member Services Supervisor in handling difficult and/or complex member situations; Assists with the preparation and monitoring of the department budget; and Serves as liaison to county Department of Social Services and Social Security Administration offices. 2. Responsible for the development and updating of member informing, outreach and marketing materials: Oversees development and dissemination of member literature, including revisions to current Member Handbook, HFP and HKP Evidence of Coverage documents as well as the development of member literature for new lines of business; producing audio and video tapes; developing ID cards, brochures and flyers; and Oversees development and production of the quarterly member newsletter; 3. Responsible for the development and implementation of staff training including HIPAA Level 2 training for Member Services Department staff. Continued on following page