Customer Service Representative *Spanish Bilingual*

Job Title: Customer Services Representative 

Department: Operations - Member Services 

• Answer all daily telephone calls from members, providers, health plans, insurance brokers, collection agents and hospitals
• Collect Elicit information from members/providers including the problem or concerns and provide general status information
• Verify authorization, claims, eligibility, and status only
• All calls carefully documented into Company’s customer service module & NMM Queue system
• Member/Provider Service/Representative assists Supervisor and Manager with other duties as assigned
• Member outreach communications via mail or telephone
• Assist Member appointment with providers
• Resolve walk-in member concerns
• Able to provide quality service to the customers
• Able to communicate effectively with customers in a professional and respectful manner
• Maintain strictest confidentiality at all times
• Specialist termination notifications sent to members
• Urgent Medicare Authorization Approval – Notification to Medicare members
• Transportation arrangement for Medicare & Medi-Cal members
• Outreach Project Assignments 

• All calls carefully documented into Company’s customer service module
• Annual Wellness Visit (AWV) – Gift card pick up and schedules
• Appointment of Representative (AOR) for Medicare Members
• Attorney / Third Party Vendor calls
• Authorization status/Modification/Redirection/CPT Code changes/Quantity adds/Explain Denied Auth/Peer to Peer calls/Extend expired auth/Pre-certified auth status/Retro/2ndor 3rd opinion/
• Conduct 3 way conference call to Health Plan with member
• Conference call with Providers – Appointments, DME,
• COVID – 19 related questions (Tests & Vaccines)
• Direct Member Reimbursement (DMR)
• Eligibility – Demographic changes: Address/Phone/Fax Changes/Name change
• Escalated calls from providers/members
• Health Diary Passport
• Health Source MSO – Assist & arrange inquiries on Eligibility/Change PCP/Benefit with AHMC
• HIPPA  Consent – Obtain Member Consent verification
• Inquiries on provider network/provider rosters
• Lab locations
• Member & Provider Complaints/Grievances
• Member bills 
• Miscellaneous calls
• Pharmacy – Drug/medication pick up and coverage
• Provide authorization status for Hospital /CM Dept
• Self-Referral Request for Medicare
• Return Mail
• Track Mail Packages/ Certified mail status
• Translations – Spanish / Chinese
• Urgent Care / locations/ operations hours

• Assist Case Management on CCS – age in 21 years for change of PCP from Pediatrics to FP/IM
• Assist Marketing on email inquiries
• Assist PR/ Elig – Members assigned to wrong PCP/with no PCP status
• Assisted UM / Medical Directors on urgent member appointment from escalated cases 
• Authorization status response call back
• Benefits – return call once information is obtained / verified 
• Complaints/Grievances – return calls once resolution is obtained
• DME – Translation support in Spanish and Chinese to confirm item / appointment set up for DME department
• Eligibility – return call to providers/labs when member is added to system while waiting at the office
• Member bills – return calls once resolution is obtained
• Member Survey – Annually: every 4thquarter
• Outreach project from internals – QCIT
• Resolve walk in members concerns
• Specialist Termination notification sent to members
• Transportation arrangement for Medicare / Medi-Cal members
• Voice mail – return calls back to callers

• Assist to contact new members/IPA member transfer on new PCP assignment as needed
• Work group discussions on work status/progress on new member/IPA transfer
• Update call log and provide daily/weekly status as needed
• Facilitate members with complex pre-existing conditions, medications, PCP/SPC network reviews
• Conference call with PCP selection / change
• Help member to identify member bill status, connect provider with on billing and claim submission
• Responsible for experience of the membership associated with new member/IPA transfer
• Responsible for to interact with Health Plan’s Customer Service Team to serve new member/IPA transfer
• Problem Solving complex cases/ brain storm with MS management team for resolution

• High School Diploma or GED
• Experience using Microsoft applications such as Word, Excel and Outlook
• Experience working in customer service
• One year related experience and/or training; or equivalent combination of education and experience
• Bilingual in Spanish

• You have previous work experience working in a healthcare setting

• Patients First
• Empowering the Independent Provider
• Be Innovative
• Operate with Integrity & Deliver Excellence
• Team of One

• This position is remotely based in California.
• This position will typically work Monday - Friday from 8:30am to 5:00pm PST.
• The total compensation target pay range for this role is $20.00 per hour. This salary range represents national target range for this role.