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Member Liaison Specialist (Bilingual, Customer Service) (3 Openings)

Company: CalOptima
Location: Orange
Posted on: June 12, 2021

Job Description:

Department(s): Member Liaison Program

Reports to: Supervisor, Member Liaison Program

FLSA status: Non-Exempt

Salary Grade: C - $41,000 - $53,000

Job Summary

This position will provide member service to seniors, persons with disabilities or chronic conditions, persons without housing and persons under the age of 21 who participate in the Whole-Child Model program. This position will serve as a liaison between members, health networks, providers and community-based organizations to facilitate access to services and help resolve healthcare and psychosocial issues. Conducts New Member Orientations and educational/informational sessions for members, providers and community-based organizations regarding CalOptima's services for members.

Position Responsibilities:

  • Assesses members' concerns to identify psychosocial or health care issues and facilitate an appropriate resolution.
  • Intakes information from members, both over the phone and in person, to complete requests for assistance cases, grievances and appeals, per departmental guidelines.
  • Coordinates members' health care and social service needs both within and outside the health network and CalOptima.
  • Addresses member and provider inquiries, questions and concerns in all areas including enrollment, claims, benefit interpretation, coordination of care, and referrals/authorizations for medical care related to services covered under the Whole-Child Model program.
  • Guides members in understanding and accessing the benefits under the Whole-Child Model program.
  • Maintains documentation of member cases within the FACETS system.
  • Initiates referrals to both internal and external care management departments, and other government agencies.
  • Communicates with community-based organizations, health networks, providers and vendors on behalf of members to resolve disputes, helps with coordinating access to care and to investigate issues preventing members from receiving medical benefits and services.
  • Collaborates with interdepartmental staff in call resolution as needed.
  • Identifies cases needing case management or escalation to a supervisor, manager, or director and routes according to established guidelines.
  • Meets all regulatory key performance indicators, first call resolution requirements and business objectives of CalOptima.
  • Other projects and duties as assigned.

Possesses the Ability To:

  • Develop rapport, establish and maintain effective interpersonal relationships with internal and external contacts at all levels.
  • Prepare and provide effective orientations and educational presentations.
  • Work with appropriate departments to expedite the resolution of member concerns.
  • Remain knowledgeable of the available health plans and CalOptima's benefit structure.
  • Speak, understand, read and/or write a second language in addition to English (may be required for some assignments).
  • Communicate clearly and concisely, both verbally and in writing with individuals from diverse backgrounds.
  • Utilize computer and appropriate software (e.g. Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems (e.g. Facets) to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Experience & Education:

  • High School diploma or equivalent required.
  • 2+ years of experience as a call center agent, or customer/member services representative in a Managed Care plan required.
  • Bilingual in English and in one of CalOptima's defined threshold languages (Spanish, Vietnamese, Arabic, Farsi, Korean, Chinese) is required.

Preferred Qualifications:

  • Bachelor's degree in Healthcare Management or related field preferred.
  • 1+ year experience working with the needs of persons with disabilities and chronic medical conditions in a customer/member service capacity is strongly preferred.
  • HMO, Medi-Cal/Medicaid, and health services experience preferred.

Knowledge of:

  • Issues that face members with special needs, such as seniors and persons with disabilities or chronic conditions and members without housing.
  • Health care service delivery and managed care principles.
  • Medi-Cal/Medicare CalOptima eligibility and benefits.
  • Techniques to serve the special needs population in diverse social and ethnic groups.
  • Methods and techniques to track and respond to service related complaints and grievances.

CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.

Keywords: CalOptima, Orange , Member Liaison Specialist (Bilingual, Customer Service) (3 Openings), Other , Orange, California

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