Salary Range: $47,875 - $71,813

Job Summary

Expectations of this position is to provide robust customer service for CenCal Healths membership and its provider network that is aligned with the Plans strategic goals and mission statement. In this role, the Member Services Representative (MSR) assists Plan membership within all programs who may have difficulty navigating, understanding and utilizing their healthcare benefits; who may have multiple and complex needs, limited communication skills and may be transitioning between levels of care and types of service. The MSR also provides assistance in the case management of Health Service Utilization, Care Management, Radiology Benefit Manager, and Pharmacy Department, by being the Plans point person for the member and provider/pharmacies in the facilitation and coordination of services with the appropriate provider.

Duties & Responsibilities

CenCal Healths MSR must embrace CenCal Healths mission and for the purpose of providing service to CenCal Healths Medi-Cal membership which consists of the underserved and vulnerable populations such as the aged, blind, disabled, Foster Care Children, Medi-Care - Medi-Cal and Long Term Care.

• Provide customer service in a queue environment within established service levels to all CenCal Health membership, advocating on their behalf in assisting with Primary Care Physician selection, obtaining appointments, transportation and interpreter services, coordination of care, referrals to County Mental Health agencies, pharmacy issues, complete documentation of complaints/appeals while providing education of program benefits;
• Respond to members concerns that include complaints and appeals; identify and assess concurrent care issues, initiate appropriate action required for the immediate resolution including forwarding to department designee for coordination with Health Services; documentation of complaint/ appeal and forward to the grievance unit for investigation and resolution;
• Assist the Plans Provider Network with eligibility, status of referrals, authorizations, claims and pharmacy medication status inquiries; and must demonstrate a thorough understanding of the relationship between the various health program agencies, Department of Social Services (DSS), Social Security Administration (SSA), Public Authority, Tri-Counties Regional Centers, Public Health Department, California Childrens Services and their relationship to CenCal Healths various healthcare program membership;
• Establish and maintain effective and cooperative working relations with internal health plan staff, outside collaborative agencies such as DSS, Public Health Department, Tri-Counties Regional Centers, California Childrens Services, Public Authority, Alcohol Drug and Mental Health for SB County and Mental Health Services for SLO County, Social Security Administration and network providers;
• Identifying, triaging and transitioning continuity of care issues; selection of Primary Care Providers (PCP); explain program/benefits and make referrals to other programs, Community Based Organizations and services, as appropriate;
• Assisting members with authorizations, assist with the coordination of health care services between the Plan, network providers (all), RBM, Specialty Pharmacy, DME, and tertiary care facilities such as UCLA and other centers of excellence to ensure continuity of care for member;
• Assist with resolving issues relating to other health coverage, including researching and documenting changes to other health coverage and notifying Recoveries and DSS as appropriate.
• Perform other duties or special projects as assigned by the Member Services Supervisor, Member Services Operations Manager or Director of Member Services
• Must be able to maneuver and understand the following screens:

• Other duties as assigned

Knowledge/Skills/Abilities

• Proven excellent customer service experience and orientation skills
• Strong oral and written communication and interpersonal/relationship building skills
• Excellent attention to detail
• Knowledge of CenCal Health and the Medi-Cal program is strongly preferred
• Demonstrate good judgment in making decisions within the scope of the position; ability to work independently with minimal supervision
• Able to multi-task in a fast paced environment
• Strong problem solving skills
• Proficiency in Word and Office Suite
• Good organizational skills

Education & Experience

• AA Degree or a minimum of three (3) years equivalent experience in a customer service environment (preferably in health care or managed care)
• Experience in public assistance or human services
• Knowledge of the Medi-Cal and Social Security programs