Member Services Navigator III - DSNP - Bilingual Spanish / Job Req 872720193

Onsite : Full Time Onsite 1240 South Loop Road, Alameda, California. Applicants must be a California resident as of their first day of employment.

PRINCIPAL RESPONSIBILITIES:

Under the Supervision of the Member Service Supervisor DSNP, a Member Service Navigator III - DSNP, you will respond to health plan member inquiries by telephone and other communication channels, providing members or prospective members with comprehensive support regarding health plan benefits and services. You will act as the primary point of contact for prospective members, and current members/authorized representative, delivering prompt, accurate, and courteous assistance, whether for general inquiries, concerns, or information requests about health care programs, services, eligibility, or benefits.

Additionally, the MS Navigator will be cross trained to serve as a Member Service Representative (MSR) or Member Liaison Special BH I (MSR, MLS BH) during periods of high call volume or staffing shortages, ensuring consistent member support and education.

Principal responsibilities include:

* Adhere to established guidelines, call scripts, and resources to address member inquiries, including maintaining the confidentiality of member information and complying with HIPAA and other relevant regulations. For non-routine inquiries, leverage available resources and expertise to resolve issues outside standard protocols.

* Know, understand and comply with internal policies and procedures to ensure compliance with CMS Part C Star Ratings Measures (CMS Secret Shopper Calls), DHCS, DMHC and NCQA standards. Attend and actively participate in regular departmental meetings, team meetings, training sessions, and coaching sessions as applicable.

* Conduct member outreach such as welcome calls and targeted member outreach calls as assigned.

* Cross training in various tasks as requested to ensure the continuity of operations within the Member Services department and other departments.

* Develop and proactively maintain up-to-date knowledge of relevant quality, regulatory, and organizational guidelines.

* Educate members and prospective members about eligibility, benefits, and our provider network. Assist members in selecting or changing their primary care physician (PCP) and provide accurate information about available providers and effective dates for PCP assignments.

* Ensure documentation is accurate and in compliance with regulatory requirements and accreditation standards.

* Handle inbound and outbound calls and other communications in a high-volume environment, providing excellent member service and professionalism following established policies and procedures and meeting performance and quality metrics.

* Intake, handle (first call resolution), and coordinate member grievances, appeals, and claims/billing issues, escalating to the Grievance and Appeals, Pharmacy, or UM department when necessary.

* Maintain health information confidentiality and follow information privacy and security best practices.

* Meet the performance goals established for the position in efficiency, call quality, member satisfaction, first call resolution, punctuality, compliance and attendance.

* Participate in and represent the company professionally at health fairs, community partnership meetings, committees, and coalitions.

* Perform problem research, use analytical skills, and effectively influence positive outcomes.

* Proactively seek opportunities to improve processes and enhance the overall member experience.

* Resolve concerns accurately, promptly, professionally, and with cultural competence; ensure that explanations are appropriate to the member's level of understanding and knowledge.

* Use listening skills and judgment to appropriately categorize and accurately document all interactions and follow-up actions regarding member communications and activities per established guidelines.

* Use strong professional judgment to determine when to escalate member inquiries to other departments. Share important information and collaborate with teams to resolve issues, including referring members to health services for care coordination and guiding providers to specialists for help with complex claims or questions.

* When applicable, refer members to appropriate community partner agencies based on their specific needs, including Behavioral Health and Recovery Services, Aging and Adult Services, Legal Aid, Human Services Agency, and HICAP.

* Maintain knowledge base of desk level procedures and stay up to date with training materials to meet regular productivity and quality departmental standards.

* Understand, know, comply with expectations for each case type: care coordination, complex, transitions of care etc.

* If appropriate, work with state and federal eligibility and enrollment staff/vendors to assist in continuity in enrollment.

* Help guide and educate members about maximizing the value of their health plan benefits and choosing a primary care provider.

* Contact care providers (doctor's offices) on behalf of the members to assist with appointment scheduling or connections with internal departments for assistance.

* Assist members in navigating AAH website while encouraging and reassuring

* Assist members in person

* Complete other duties and special projects as assigned.

* Productivity:

o Maintain adequate passing score on monthly productivity audits, including call volume and documentation volume.

o Demonstrate availability to accept incoming calls during normal business hours except when approved by leadership in advance.

* Quality and Accuracy:

o Maintaining adequate passing score (95%) on monthly audits

* Compliance:

o Maintaining adequate passing score (95%) on monthly audits

* Attendance and Punctuality:

o Maintaining adequate passing score on monthly audits

ESSENTIAL FUNCTIONS OF THE JOB:

* Telephone: Complete and document all telephone calls to members and explain health plan program benefits to Alliance members. Describe the types of services the Alliance and other community partners offer.

* Computer: Accurately maintain member database to ensure data integrity.

* Meetings: Participate in departmental and non-departmental meetings and other scenarios.

* Perform writing, administration, data entry, analysis, and report preparation.

* Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

* Maintain adaptability and flexibility; engage in cross-training to acquire skills and knowledge for various responsibilities.

* Apply cross-training methods to minimize call transfers and escalations, supporting resolution during initial contact and enhancing customer satisfaction.

* Serve as the main contact across several Alliance Member Services channels, including phone queues, in-person engagements, mail, email, and the online member portal.

* Respond to inquiries by answering calls and providing precise information regarding Alliance plans, benefits, eligibility, and enrollment procedures.

* Manage concerns and complaints by resolving complex member issues and de-escalating challenging situations, following federal, state, and contractual guidelines while maintaining customer service standards.

* Investigate complex issues and ensure their resolution.

* Exhibit thorough understanding of coverage and benefits to support appropriate service usage per DHCS, DMHC, CMS, and NCQA guidelines.

* Attend required departmental and non-departmental meetings.

* Present information about Alliance and community partner services in a clear and culturally respectful manner.

* Follow AAH policies and procedures and adhere to DMHC, DHCS, CMS, NCQA regulatory standards, including PHI/HIPAA compliance.

* Develop solutions to challenges and opportunities as they arise.

* Remain informed about available health plans and AAH's benefits to assist members accurately.

* Communicate both verbally and in writing effectively with a diverse audience.

PHYSICAL REQUIREMENTS:

* Constant and close visual work at a desk or a computer.

* Constant sitting and working at a desk.

* Constant data entry using multiple monitors, keyboard and/or mouse.

* Frequent use of telephone headset.

* Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.

* Frequent lifting of files, binders and other objects weighing between 0 and 30 lbs.

* Frequent walking and standing.

EDUCATION OR TRAINING EQUIVALENT TO:

* High School Diploma or GED required.

* Bachelor's degree or combination of education and equivalent work experience which would provide the required knowledge, skill and abilities may qualify.

* Two years of experience in behavioral health, community services, or other social services setting are required.

* Experience in working with children diagnosed with ASD or ABA services preferred.

* Customer service: call center experience preferred.

* Managed Care, HMO, Medi-Cal/Medicare, and health services experience preferred.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

* One year's experience in triage, intake or care coordination.

* 2 years' experience in Customer Service or call center role, member facing, preferably in a health care or public-sector setting.

* 2 years' recent experience with managed care plans, Medi-Cal and Medicare programs, and working with underserved populations.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

* The ability to speak and understand-bilingual: Spanish/English, Cantonese/English, Mandarin/English, Vietnamese/English, Tagalog/English, Arabic/English, Farsi/English are required as designated.

* A bilingual proficiency exam will be administered to ensure the candidate possesses the appropriate skill level to meet requirements. The successful candidate must score 90% or higher.

* Fluency in English required.

* Proficiency in correct English usage, grammar, and punctuation.

* Demonstrates telephone etiquette and patience.

* Able to communicate and collaborate with a variety of providers and individuals.

* Preferred experience working with individuals with complex health needs.

* Preferred experience with de-escalation techniques.

* Preferred completion of AHIP's Medicare + Fraud, Waste, and Abuse (MFWA) training.

* Preferred experience in crisis intervention and mental health services.

* Experience in Utilization Management, Case Management, Care Coordination, or Telephonic Case Management is beneficial.

* Familiarity with state and federal insurance programs is advantageous.

* Knowledge of Alameda County community resources, Medicare, Medi-Cal, HICAP, Health Care Options, and Social Services.

* Basic understanding of medical concepts, including the ability to identify medical and social risk factors, knowledge of chronic disease conditions, and familiarity with common treatment options.

* Experience triaging crisis calls from members and escalating when necessary.

* Ability to work assigned shifts during Alliance operating hours, including the training period, with designated lunch and break times, and flexibility for schedule adjustments, overtime, and weekend work as needed.

* Experience in assessing callers' needs and efficiently directing them to the appropriate individual or department.

* Strong computer and typing proficiency

* Proficient experience in Windows including Microsoft Office suite.

* Knowledge of Health insurance and medical terminology, call center best practices and quality metrics.

* Good analytical and interpretive skills.

* Strong organizational skills, proactive and detail oriented.

* Sensitivity to a diverse, low-income community.

* Excellent critical thinking and problem-solving skills.

* Ability to act as a resource.

* Excellent presentation, customer service and delivery skills.

* Experience in providing support to members enrolled in a Medicare Advantage plan designed for individuals eligible for both Medicare and Medicaid, by answering questions regarding benefits, claims, care coordination, and addressing any concerns they may have regarding their healthcare needs preferred

* Demonstrate understanding of complex medical and insurance policies related to dual eligibility.

* Demonstrate outstanding service to identify the source of the caller's issue and work to resolve the inquires in a timely and professional manner

* Familiarity with Alameda County resources a plus.

* Familiar with quality metrics relevant to a call center and best practices for achieving them.

* Ability to prioritize and adapt to changing situations in a calm and professional manner.

* Ability to maintain composure in stressful situations.

* Ability to type 40 net words per minute: multi-task

* Demonstrated ability to listen skillfully, collect relevant information, determine immediate requests, and identify the current and future needs of the members.

* Must be self-motivated and able to work with minimal supervision.

* Must be team-oriented and focused on achieving organizational goals.

* Proficient in translating healthcare-related jargon and complex processes into simple, step-by-step instructions which members can understand and act upon.

* Proficient conflict management skills to include ability to resolve issues during stressful situations and demonstrating personal resilience.

Employees who interact with members of the public may be required to be tested for Tuberculosis and fully vaccinated against COVID-19 and influenza. Successful candidates for those positions/ classifications may be required to submit proof of vaccination against influenza and/or COVID-19, a negative Tuberculosis test, or request an exemption for qualifying medical or religious reasons during the onboarding process. Candidates should not present proof of vaccination until instructed to do so by the Human Resources department.

SALARY RANGE $30.26 - $45.40 Hourly

The Alliance is an equal opportunity employer and makes all employment decisions on the basis of merit and business necessity. We strive to have the best-qualified person in every job. The Alliance prohibits unlawful discrimination against any employee or applicant for employment based on race, color, religious creed, sex, gender, transgender status, age, sexual orientation, national origin, ethnicity, citizenship, ancestry, religion, marital status, familial status, status as a victim of domestic violence, assault or stalking, military service/veteran status, physical or mental disability, genetic information, medical condition, employees requesting accommodation of a disability or religious belief, political affiliation or activities, or any other status protected by federal, state, or local laws.