Job Details

Location: Hybrid in Santa Barbara office 2 times per week. During training, will need to be in office 3-5 times per week.

Description:
Expectations of this position is to provide robust customer service for all membership and its provider network thatis aligned with the Plan's 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, Transportation coordination and the Pharmacy Department, by being the Plan's "point of contact" for the member and provider/pharmacies in the facilitation and coordination of services with the appropriate provider.

What You Will Do:

• Provide customer service in a queue environment within established service levels to all 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 Plan's "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 Children's Services, and their relationship to the plan's 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 Children's 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.
• Assist members with member portal guidance and questions; including proving information on what the portal provides, and general account guidance.
• Assist the Call Center management team in responding and assisting members with their web inquiries.
• Must be able to maneuver and understand the following screens:
  • Eligibility and its nine sub-screens
  • MEDSLite & CalSAWS
  • Adjudication
  • Member Grievance - COG
  • HIS-Call Tracking System
  • Provider
  • Cisco Agent Desktop
  • Medslite
  • RBM
  • Authorization Processing (TAR)
  • Claim Search
  • Problem Claim Check
  • Standard Report
  • Procedure
• Other duties as assigned

You Will Be Successful If:

• Proven excellent customer service experience and orientation skills
• Strong oral and written communication and interpersonal/relationship building skills
• Excellent attention to detail
• Knowledge of 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

What You Will Bring:

• Experience working in a healthcare, human services, or public assistance environment in an administrative capacity, directly supporting the population utilizing medi-cal services (e.g., medical receptionist, regional center coordinator, patient advocacy, or related roles).
• Bilingual in Spanish preferred

About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.

Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do - provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.

That's Impresiv!