About the Role

Astrana Health is looking for a Member Service Representative to join our fast and growing dynamic team. What You'll Do :

• Answer all daily telephone calls from members, providers, health plans, insurance brokers, collection agents and hospitals
• Collect Elicit information from members / providers including the problem or concerns and provide general status information
• Verify authorization, claims, eligibility, and status only
• All calls carefully documented into Company’s customer service module & NMM Queue system
• Member / Provider Service / Representative assists Supervisor and Manager with other duties as assigned
• Member outreach communications via mail or telephone
• Assist Member appointment with providers
• Resolve walk-in member concerns
• Able to provide quality service to the customers
• Able to communicate effectively with customers in a professional and respectful manner
• Maintain strictest confidentiality at all times
• Specialist termination notifications sent to members
• Urgent Medicare Authorization Approval Notification to Medicare members
• Transportation arrangement for Medicare & Medi-Cal members
• Outreach Project Assignments

INBOUND CALLS : Member / Provider / Health Plan / Vendor / Hospital / Broker :

• All calls carefully documented into Company’s customer service module
• Annual Wellness Visit (AWV) Gift card pick up and schedules
• Appointment of Representative (AOR) for Medicare Members
• Attorney / Third Party Vendor calls
• Authorization status / Modification / Redirection / CPT Code changes / Quantity adds / Explain Denied Auth / Peer to Peer calls / Extend expired auth / Pre-certified auth status / Retro / 2ndor 3rd opinion /
• Conduct 3 way conference call to Health Plan with member
• Conference call with Providers Appointments, DME,
• COVID 19 related questions (Tests & Vaccines)
• Direct Member Reimbursement (DMR)
• Eligibility Demographic changes : Address / Phone / Fax Changes / Name change
• Escalated calls from providers / members
• Health Diary Passport
• Health Source MSO Assist & arrange inquiries on Eligibility / Change PCP / Benefit with AHMC
• HIPPA Consent Obtain Member Consent verification
• Inquiries on provider network / provider rosters
• Lab locations
• Member & Provider Complaints / Grievances
• Member bills
• Miscellaneous calls
• Pharmacy Drug / medication pick up and coverage
• Provide authorization status for Hospital / CM Dept
• Self-Referral Request for Medicare
• Return Mail
• Track Mail Packages / Certified mail status
• Translations Spanish / Chinese
• Urgent Care / locations / operations hours

OUTBOUND CALLS : Member / Provider / Health Plan / Vendor / Hospital / Broker :

• Assist Case Management on CCS age in 21 years for change of PCP from Pediatrics to FP / IM
• Assist Marketing on email inquiries
• Assist PR / Elig Members assigned to wrong PCP / with no PCP status
• Assisted UM / Medical Directors on urgent member appointment from escalated cases
• Authorization status response call back
• Benefits return call once information is obtained / verified
• Complaints / Grievances return calls once resolution is obtained
• DME Translation support in Spanish and Chinese to confirm item / appointment set up for DME department
• Eligibility return call to providers / labs when member is added to system while waiting at the office
• Member bills return calls once resolution is obtained
• Member Survey Annually : every 4thquarter
• Outreach project from internals QCIT
• Resolve walk in members concerns
• Specialist Termination notification sent to members
• Transportation arrangement for Medicare / Medi-Cal members
• Voice mail return calls back to callers

CONCIERGE SERVICES ESSENTIALS DUTIES AND REQUIREMENTS :

• Assist to contact new members / IPA member transfer on new PCP assignment as needed
• Update call log and provide daily / weekly status as needed
• Facilitate members with complex pre-existing conditions, medications, PCP / SPC network reviews
• Conference call with PCP selection / change
• Help member to identify member bill status, connect provider with on billing and claim submission
• Responsible for experience of the membership associated with new member / IPA transfer
• Responsible for to interact with Health Plan’s Customer Service Team to serve new member / IPA transfer
• Problem Solving complex cases / brain storm with MS management team for resolution

Qualifications :

• High School Diploma or GED
• Experience using Microsoft applications such as Word, Excel and Outlook
• Experience working in customer service
• One year related experience and / or training; or equivalent combination of education and experience.
• Bilingual in Mandarin / Cantonese

You're a great for this role if :

• You have previous work experience working in a healthcare setting

Last updated : 2024-04-25