Member Liaison Specialist (Bilingual, Customer Service) (3 Openings)
Posted on: June 12, 2021
Department(s): Member Liaison Program
Reports to: Supervisor, Member Liaison Program
FLSA status: Non-Exempt
Salary Grade: C - $41,000 - $53,000
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.
- 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
- Guides members in understanding and accessing the benefits
under the Whole-Child Model program.
- Maintains documentation of member cases within the FACETS
- 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
- Collaborates with interdepartmental staff in call resolution as
- Identifies cases needing case management or escalation to a
supervisor, manager, or director and routes according to
- 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
- Prepare and provide effective orientations and educational
- Work with appropriate departments to expedite the resolution of
- 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
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
- Bilingual in English and in one of CalOptima's defined
threshold languages (Spanish, Vietnamese, Arabic, Farsi, Korean,
Chinese) is required.
- Bachelor's degree in Healthcare Management or related field
- 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
- Issues that face members with special needs, such as seniors
and persons with disabilities or chronic conditions and members
- 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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