POSITION SUMMARY
Drives customer loyalty and provides excellent telephonic customer service to our customers (members and providers). This position will work with other departments in order to respond to customer and provider concerns in a timely and effective manner.
COMPLIANCE WITH REGULATIONS
Works closely with all departments necessary to ensure that the processes, programs, and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D, DHCS and DMHC.
RESPONSIBILITIES
Resolves member concerns in a timely manner by recommending and facilitating options including:
Coordinates urgent care accessibility by providing locations or scheduling appointment at urgent care of members choice
Coordinates interpreter services for non-English speaking members by scheduling an in-person interpreter or connecting to the phone interpreter
Arranges member transportation: assist with MTS applications, send taxi vouchers, or mail bus/trolley passes.
Provides information regarding prior authorization requests and/or provides status.
Makes Primary Care Provider changes based on member needs or preference.
Assists with medication processing by speaking to the pharmacy.
Refers and transferring to Telephone Advice Nurse for health-related questions.
De-escalates difficult members by providing excellent customer service and giving options.
Coordinates and facilitates emergency transfers of the site and providing enrollment verification to providers involved.
Documents all member and provider communications by entering the following:
Issue statements- identifying the main reason for the call
Steps to resolve- showcasing the representatives work towards a resolution
Issue Resolutions- summarizing the reason and outcome of the call
Assists in primary care site discharge by reviewing provider requests and providing available options to members while ensuring a smooth transition.
Educates provider of 30-day responsibility after dating of discharge, a member may return to the office for emergency visits or prescription fills.
Provides member assistance with bills received from providers by documenting and referring to bills liaison.
Contacts billing provider to educate on process and submission of a claim to plan.
Completes “Welcome Calls” within the first two weeks of every month (will require about 10 hours of overtime per month).
Informs member of plan benefits and ID card
Informs member of home visits after a hospital visit
Works effectively with all departments in the organization to accomplish member care and provider/vendor assistance.
Utilization Management- Educates providers on the process and assist in the location of request forms and instructions. Relays provider requests to change/update authorizations, faxing authorizations to non-contracted providers. Assist members with authorization information and simplifying content
Grievance Department- Works closely with the Grievance and Appeal Department by referring exempt cases meeting the criteria for grievance classification for further follow-up and resolution. Ensures all pertinent information is forwarded to the G&A team. Initiate non-exempt grievances and adheres to sensitive timelines. Evaluates data to determine and implement the appropriate course of action to resolve the complaint.
In-patient- Assists with outbound calls if necessary and transfer providers requesting inpatient assistance.
Pharmacy- Assists pharmacy with outbound calls to members or requesting overrides when they cannot be completed by the Helpdesk.
Enrollment- Communicates to Enrollment when a member needs to be dis-enrolled due to: moving out of the area, expiring member, not active according to MediCal Website. Manually mail out all member ID cards received from the Enrollment team.
Marketing- Completes marketing form for CMC and Medi-Cal lines of business and sends to COO for review and distribution. Assist marketing representatives with answering member or provider questions when out on the field.
HEDIS- Assists with outbound calls to members for possible primary care provider changes. Assist with scheduling appointments for annual exams such as mammogram, physical, colonoscopy.
Case Management- Prioritizes CMC calls rolled over to Medi-Cal ACD and assists members with first call resolution. Communicate home visit opportunities to case/care manager for follow-up.
Behavioral Health- Transfers all Behavioral Health-related calls to the BH team when they come In through the Medi-Cal ACD line. Assist members in crisis by staying on the phone with them while a BH representative comes to take control of the call, and requesting a wellness check with the police department.
Compliance- Refers any fraud, waste, and abuse-related cases to the Compliance department for follow-up. Consistently supports compliance by maintaining the privacy and confidentiality of information, protecting members’ PHI, acting with ethics and integrity, and reporting non-compliance to the appropriate department.
Provider Relations- Connects providers inquiring on claim status or provider portal issues to Provider Relations Team.
IS/IT- Reports any software and hardware issues to IS team and testing any updates or changes made to the software.
Credentialing- Forwards provider information to Credentialing team if there have been demographic changes. Send information to Credentialing team if the provider directory has any errors such as: missing contracted provider information, provider shows that they are accepting new members when they are not, and incorrect address/phone number.
Contracting- Sends information of providers interested in becoming part of the CHG network.
Works closely with community-based ethnic service and advocacy programs by identifying the members or families’ non-medical and social needs and referring these to the appropriate organizations for assistance.
Connect member to 211 services
Uses specialized internet sites to find community resources that fit the members’ needs
Maintains product and company reputation by conveying a professional image, and contributes to the team effort by accomplishing related tasks:
Participating in committees and in meetings
Professionally represents the company at community functions
Performing other duties as assigned or requested.
Embodies the company’s customer service philosophy of MAGIC
Participate in the department’s on-call schedule, which includes after business hours, weekends, and holiday coverage.
Follow established procedures to meet member, provider, and vendor needs
Identifies operational issues preventing the delivery of exceptional customer service by documenting and referring these to Customer Relations Supervisors for follow-up and resolution.
Assist department in reaching call handling goals, first call resolution goals, complaint resolution, member retention, and closing all cases initiated by a representative.
Accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to the team, members, providers, and any external vendors.
Identifies and initiates continuity of care for qualifying members.
Works with State and local IPA’s (CSSD and CCS) and follows their guidelines and procedures
Maintains the telephone abandonment rate within 1% by working as a team in answering incoming Customer Service telephone lines.
Perform other duties as required
Work on special projects as required- short or long-term projects.
Qualifications
EDUCATION
Bachelor’s Degree
EXPERIENCE/ SKILLS
Two years of experience in Customer Service (preferably in the health care industry).
Strong customer service background.
Familiarity with case documentation practices.
Experience with and sensitivity to cultural background and linguistic needs of membership.
Familiarity and respect for special social needs of Medi-Cal populations.
Knowledge of Medi-Cal program eligibility requirements and familiarity with services available through community based ethnic service and advocacy organizations throughout San Diego preferred.
Familiarity with foundations and practices of public health, Medical Care Organization and Delivery.
Understands Public Health Communications.
Bilingual English/Spanish, English/Vietnamese, or English/Arabic.
Excellent communication and interpersonal skills.
Ability to exercise mature and independent judgment.
Typing skills
Physical Requirements:
Prolonged periods of sitting.
Extensive use of telephone.
Will be required to work evenings and/or weekends.
Apply Now
To help us with our recruitment effort, please indicate your email/cover letter where (vacanciesiniraq.com) you saw this job posting.