Description

POSITION SUMMARY

Drives customer loyalty and provides excellent customer service to our customers (Medicare members and providers). This position will work with other departments in order to respond to Medicare member concerns in a timely 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

• Use effective information gathering strategies that will help to improve the health of our Medicare members and obtain desired results.

• Conducts home visits for assigned case load.

• Assists members so they obtain needed STARS/HEDIS related health care services.

• Collects current phone numbers, email addresses, etc. to help ensure communication with the members.

• Resolves Medicare member concerns in a timely manner by recommending and facilitating available options.

• Coordinates urgent care appointments, interpreter services for non-English speaking Medicare members, transportation and prior authorization requests.

• Gathers information on our Medicare member from a number of different sources (medical, non-medical, home environment, caregiver, family etc).

• Work closely with other professionals to coordinate care for our Medicare members (includes medical, behavioral health, social, community-based and other services).

• Is in constant contact with Medicare members and their families/caregivers to ensure their needs are addressed in the most effective manner.

• Coordinates and facilitates emergency transfers of site and enrollment verification.

• Assists in primary care site transfers by reviewing Medicare member requests and providing available options before initiating the transfer process

• Documents all communications by entering a summary of the Medicare member’s concern, options offered to resolve the issue, and any other relevant information.

• Meets or exceeds all phone call benchmarks (time to answer call, first call resolution, abandonment rate, etc.).

• Identifies operational issues preventing the delivery of good customer service by documenting and referring these to management for follow-up and resolution.

• Refers cases meeting the criteria for grievance classification or plan-initiated disenrollment to management for further follow-up and resolution.

• Provides assistance with bills received from providers by documenting and referring to Claims department provider bills received by Medicare members for services authorized and/or covered by Community Health Group.

• Participate in the department’s on-call schedule, which includes after business hours, weekend and holiday coverage.

• Complete “Welcome Calls” within the first two weeks of every month (will require about 10 hours of overtime per month).

• Works closely with community based ethnic service and advocacy programs by identifying the Medicare member’s/family’s non-medical and social needs and referring these to the appropriate organizations for assistance.

• Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.

Qualifications

EDUCATION

• Bachelor's Degree in a Health or Human Services Field required (Health Education, Psychology, Sociology, Health Sciences, Public Health, Social Work, Nursing)

• Within one year of eligibility, must take the Certified Case Manager test. Must pass the test within 12 months of the date of eligibility to retain employment.

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 Medicare populations.

• Knowledge of Medicare program eligibility requirements and familiarity with services available through community based ethnic service and advocacy organizations throughout San Diego preferred.

• Bilingual English/Spanish, English/Vietnamese, or English/Arabic

• Excellent communication and interpersonal skills.

• Ability to exercise mature and independent judgment.

• Ability to secure reliable transportation and possess a valid driver’s license as well as proof of vehicle insurance

PHYSICAL REQUIREMENTS

• Prolonged periods of sitting.

• Extensive use of telephone.

• Will be required to work evenings and/or weekends.

**Must have current authorization to work in the USA**

Community Health Group is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our org
anization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, and trainings. Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, see Personnel Policy 3101 Equal Employment Opportunity/Affirmative Action .