Member Services Representative

Essential Duties and Responsibilities

Essential Duties and responsibilities include, but are not limited to:

·         Conduct outbound calls for CAHPS, HEDIS , AHA , IHA, Member Birthdays, Member Coordination Port Discharge, Coordination of Care and other assigned program outreaches.

·         Explain the medications, protocols, benefits, services, and any other necessary information to the members who telephones PCAC.

·         Schedule and complete 85% of AHA outreaches.

·         Schedule and complete 90% of post discharge members.

·         Maintain a minimum of 5-star rating for all conducted outreaches.

·         Ensure that a 95-100% of goals are met by set timelines. 

·         Every incoming call must be typed during the course call. Every contact must be documented with pertinent details (i.e., caller’s name, contact info., reason for call, action taken, resolution, etc.,)

·         Make all attempts to assist patient in obtaining required care and coordinate with assigned team members, provider offices to guarantee the member receives the care needed, which may include patient home visits.

·         Identify challenges, errors , problems with-in department and conduct follow-up actions to resolve matters in timely matter to maintain the proper workflow of assigned outreach. 

·         Respond to complaints against Primary Care Associates of CA (PCAC) and its contracted facilities by utilizing the departments Complaint/Grievance Policy and Procedure.

·         Collaborate and Coordinate with QI department team members (PL Team, Medication Adherence, Member Care Advocate team and other team members as needed)  to complete all outreaches in appropriate time frame.

·         Answer all incoming member phone calls within the department’s goal timeframe.

·         Assist members with their needs. Schedule and arrange member appointments as necessary.

·         Maintain proper documentation.

·         Meet all department goals.

·         Assist with outreach mailers.

·         Schedule and complete authorization appointments as assigned.

·         Document all aspects with accuracy and detail

·         Foster good corporate relations by practicing good customer service principles (i.e., positive attitude, helpful, etc.).

·         Schedule visits to PCP offices to conduct outreach and member care coordination to ensure all HEDIS measures are completed.

·          Perform other duties assigned by department director

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.       Education and/or Experience: High School or general education degree (GED); or on to three months related experience and/or training; or equivalent combination of education and experience.

2.       Medical Assistance Certificate: Not required but preferred

3.       Phlebotomy License: Preferred but not required

Other Qualifications:

1.       Two years customer service

2.       Health Plan Outreach Experience

3.       Direct member communication, preferably in the Medi-Cal, Commercial, or Medicare Managed Care industry preferred.

4.       Knowledge of Medi-Cal, Commercial, and Medicare Managed Care Plans preferred.

5.       Bilingual (English/Spanish) required.

Skills and Abilities

·         Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization.

·         Mathematical Skills: Ability to add and subtract two-digit numbers and to multiply and divide with 10s and 100s. Ability to perform these operations using units of American money and weight measurement, volume and distance.

·         Reasoning Skills: Ability to apply common sense understanding to carry out detailed but variables in standardized situations.

·         Computer Skills: Strong computer skills.

Other skills and Abilities

·         Computer literate. Typing 40+ words per minute.

·         Excel proficiency

·         Excellent communication skills, oral and written.