Sr. Director, Member Services Call Center

Directs case management activities across multiple units and/or departments by determining and overseeing the strategic direction for process inefficiencies. Ensures that case management and resolution activities are performed in compliance with internal and external rules and regulations. Championing advanced long-term strategies for improving and addressing process inefficiencies in case research. Determines and oversees strategic plans for high priority incident case resolution based on expert knowledge and future industry directions. Champions exceptional customer and member services through training, process, and procedures. Integrates cutting edge knowledge of the incident management process, relevant laws, regulations, statutes, federal policy changes, and other organization-wide initiatives to identify and address operational gaps that contribute to member and provider dissatisfaction, unnecessary appeals cases, or group retention issues. Evaluates data and identifies trends to conduct root cause analysis, identify stakeholders with whom to improve consumer experience, and implement operational solutions. Leads and communicates new policies which facilitate operational changes and ensure effective change management.

• Builds organizational capacity and prepares high potentials for growth opportunities and advancement; builds collaborative networks inside and outside the organization for self and others. Provides framework for soliciting and acting on performance feedback; drives collaboration to set goals and provide open feedback and coaching to foster performance improvement. Models and drives continuous learning and oversees the recruitment, selection, and development of talent; stays current with industry trends, benchmarks, and best practices; ensures performance management guidelines and expectations to achieve business needs. Acts as a thought leader on industry trends, benchmarks, and best practices; shares best practices within and across teams to drive improvement. Motivates and empowers teams; maintains a highly skilled and engaged workforce by aligning cross-functional resource plans with business objectives. Provides guidance when difficult decisions need to be made; creates opportunities for expanded scope of decision making and impact across teams.


• Oversees the operation of multiple units and/or departments by identifying member and operational needs; ensures the management of work assignment allocation and completion; translates business strategy into actionable business requirements; ensures products and/or services meet member requirements and expectations while aligning with organizational strategies. Engages strategic, cross-functional business units to champion and drive support for business plans and priorities; assumes responsibility for decision making; sets standards, measures progress, and ensures resolution of escalated issues. Sets and communicates goals and objectives; analyzes resources, costs, and forecasts and incorporates them into business plans; obtains and distributes resources. Anticipates and removes obstacles that impact performance; addresses performance gaps and implements contingency plans accordingly; ensures teams accomplish business objectives; serves as a subject-matter expert and trusted source to executive leadership; provides influence and consultation in the development of the larger organizational or business strategy.


• Directs member incident case management by: evaluating and determining for incidence case management strategic initiatives and operation visional using data and trends from the case tracking database; determining and overseeing the strategic direction for addressing process inefficiencies in case management, such as case volumes that are too high or low, across multiple teams or regions, as well as processing highly complex or high risk cases and managing highly complex teams across all lines of business; and ensuring that case management activities are performed in compliance with internal and external rules and regulations across multiple units and/or departments.


• Promotes member incident case research by: championing advanced long-term strategies for improving and addressing process inefficiencies related to incident case research activities across members and customers across multiple units and/or departments that has organization-wide impacts.


• Establishes strategies for the resolution of member incident cases by: determining and overseeing strategic plans to address high priority incident resolution needs based on expert knowledge of future industry directions; and championing processes for incident resolution that are effective and compliant with internal and external rules across multiple units and/or departments.


• Promotes customer service by: determining and driving improved long-term strategies to ensure overall member communication (i.e. information provided to members, customers, or other stakeholders from staff related to concerns/incidents) is accurate and timely, meets or exceeds program wide and consumer expectations; and championing exceptional customer and member service through establishing training, processes, and procedures that address cases involving highly charged, sometimes emotional situations and updating communication processes for incident resolution across multiple units and/or departments to ensure effectiveness and compliance with internal and external rules and regulations.


• Impacts case documentation efforts by: improving data collections processes to ensure that all relevant information to address cases is being gathered to ensure regulatory compliance, audit readiness, and that data can be used to drive upstream improvements that have organization-wide impacts; and driving long-term strategic documentation processes for multiple units and/or departments to ensure that all quality and regulatory standards are being met.


• Serves as a leader for operational improvement by: integrating cutting edge knowledge of the incident management process, relevant laws, regulations, statutes, federal policy changes, and other organization-wide initiatives to identify and address operational gaps that contribute to member and provider dissatisfaction, unnecessary appeals cases, or group retention issues; evaluating data and identifying trends to conduct root cause analysis, identify stakeholders with whom to improve consumer experience, and implement operational solutions; and leading and communicating new policies which facilitate operational changes and ensure effective change management across multiple units and/or departments.