Customer Service Representative I (Spanish Speaking)

Department: Ops - Member Services

Employment Type: Full Time

Location: 9700 Flair Drive, El Monte, CA 91731

Reporting To: Stephen Crowley

Compensation: $18.90 - $24.25 / hour

Description

What You'll Do

• 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  

• Member/Provider/Health Plan/Vendor/Hospital/Broker: 
• 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 
• Other duties as assigned

Qualifications

• 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
• You are fluent in Spanish

• You have previous work experience working in a healthcare setting 

Environmental Job Requirements and Working Conditions

• This is a remote role. The home office is aligned with your department at 9700 Flair Drive, El Monte, CA 91731
• This position will typically work Monday - Friday from 8:30am to 5:00pm PST.
• The target pay range for this role is $18.90 - $24.25 per hour. This salary range represents national target range for this role. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.