Description

POSITION SUMMARY

Drives customer loyalty and provides excellent telephonic customer service to our customers (members and providers). This position will work with other departments in order to respond to customer and provider concerns in a timely and effective manner.

COMPLIANCE WITH REGULATIONS:

Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D, DHCS and DMHC.

RESPONSIBILITIES

• Deliver exemplary members service to members, addressing inquiries and concerns about health plan benefits, coverage, claims, and enrollment with adherence to the 33 MAGIC principles, exceeding member expectations.
• Consistently achieve ratings within the "Exceptional" tier across the 33 dimensions of MAGIC.
• Interpret complex health plan information accurately and timely for members and healthcare providers, utilizing an in-depth understanding of health plan structures, services, and the regulatory environment.
• Forge and collaborate effectively with internal teams and healthcare professionals to ensure a unified, comprehensive, and seamless approach to member support.
• Cultivate a profound comprehension of all health plan products, services, and pertinent regulatory mandates, ensuring compliance and contemporary knowledge in all service encounters.
• Play a pivotal role in developing strategies to elevate the member service experience and maximize operational efficiency through the nuanced analysis of member reactions and emotions and identifying behavioral patterns and barriers to service delivery.
• Safeguard sensitive information with the utmost integrity and confidentiality, protecting member data against unauthorized access or disclosure.
• Personalize and tailor experience and solutions to meet individual members' needs and preferences.
• Advocate and champion members' needs and desires, ensuring their voices are heard and acted upon within our regulatory constraints.
• Initiates and sustains meaningful interactions with members, building lasting relationships.
• Guide members through complex information or decisions with ease and expertise.
• Independently addresses and solves members' issues, ensuring satisfaction and loyalty.
• Introduces new ideas and approaches to enhance the member's experience and meet emerging needs.
• Craft customized solutions and experiences that exceed members' expectations.
• Offer expert advice and solutions to members, helping them make informed decisions.
• Implement approved strategies aimed at improving members' engagement and satisfaction.
• Understand and respond to members' emotions and needs with compassion and personalized care.
• Makes it easier for members to navigate services or products, enhancing their overall experience.
• Continuously improves members' interactions and services for peak efficiency and satisfaction.
• Predict member's needs and preferences, proactively offering solutions and support.
• Provide members with the knowledge and resources they need to maximize the use of the products or services offered.
• Skillfully discuss options with members, reaching mutually beneficial agreements.
• Contribute to formulating and revising member service protocols and guidelines, ensuring adherence to state and federal regulatory standards.
• Exercise independence in decision-making with minimal oversight, confidently managing responsibilities while aligning with organizational goals.
• Apply advanced problem-solving abilities to navigate and resolve complex situations, driving continuous improvement in service quality.

Qualifications

EDUCATION

• Bachelor's Degree

EXPERIENCE/ SKILLS

• Two years of experience in Member Services (preferably in the health care industry).
• Strong customer service background.
• Familiarity with case documentation practices.
• Experience with and sensitivity to cultural background and linguistic needs of membership.
• Familiarity and respect for special social needs of Medi-Cal populations.
• Knowledge of Medi-Cal program eligibility requirements and familiarity with services available through community based ethnic service and advocacy organizations throughout San Diego preferred.
• Familiarity with foundations and practices of public health, Medical Care Organization and Delivery.
• Understands Public Health Communications.
• Bilingual English/Spanish, English/Vietnamese, or English/Arabic.
• Excellent communication and interpersonal skills.
• Ability to exercise mature and independent judgment.
• Typing skills

PHYSICAL REQUIREMENTS

• Prolonged periods of sitting.
• Extensive use of telephone.
• Will be required to work evenings and/or weekends.

Community Health Group is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, and trainings. Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, see Personnel Policy 3101 Equal Employment Opportunity/Affirmative Action

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.