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.
Requirements
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 Gamp;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 Medi-Cal 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