Member Services Specialist - Bilingual Spanish

Community Health Group is a locally based non-profit health plan that ensures access to high quality, culturally sensitive health care for underserved communities throughout San Diego County. We treat our 300-member, multi-lingual staff like family, encouraging an atmosphere of collaborative teamwork, continuous learning, personal growth, and promotion from within. Recognized as one of the Top Workplaces in San Diego, CHG offers its employees such benefits as tuition reimbursement, a meditation room and yoga classes, a monthly Breakfast With The CEO, and memorable events throughout the year.

We know that by serving our employees well, they, in turn, will better serve our nearly 250,000+ membership. We have been recognized consistently for the excellence and sensitivity of our customer service by members, physicians, vendors, and a full range of health care providers. We are accredited by the National Committee for Quality Assurance and proud of our continuing company-wide Quality Initiatives.

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 in person interpreter or connecting to over the phone interpreter
  • Arranges member transportation: assist with MTS applications, send taxi voucher, or mail bus/trolley passes.
  • Provides information regarding prior authorization requests and/or provide status.
  • Makes Primary Care Provider changes based on member needs or preference.
  • Assists with medication processing by speaking to 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 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 resolution
  • Issue Resolutions- summarizing the reason and outcome of the call
• Assists in primary care site discharges by reviewing provider requests and providing available options to member while ensuring a smooth transition.
  • Educates provider of 30 day responsibility after date of discharge, member may return to 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 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 process and assist in location of request form 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 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 Helpdesk.
  • Enrollment- Communicates to Enrollment when member needs to be dis-enrolled due to: moving out of area, expiring member, not active according to MediCal Website. Manually mail out all member ID cards received from Enrollment team.
  • Marketing- Completes marketing form for CMC and Medi-Cal lines of business and send 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 assist 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 BH team when they come In through Medi-Cal ACD line. Assist members in crisis by staying on the phone with them while a BH representative comes to take control of call, and requesting a wellness check with police department.
  • Compliance- Refers any fraud, waste, and abuse related cases to 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 software.
  • Credentialing- Forwards provider information to Credentialing team if there have been demographic changes. Send information to Credentialing team if 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 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 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 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.

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.