Customer Relations Specialist - Bilingual English/Spanish
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 • Resolves member concerns in a timely manner by recommending and facilitating available options including follow-up with provider of services by coordinating urgent care appointments, interpreter services for non-English speaking members, member transportation and prior authorization requests. • Coordinates and facilitates emergency transfers of site and enrollment verification. • Identifies cases qualifying for an emergency disenrollment and works with Enrollment Contractor on the timely approval/resolution of these cases. • Documents all member communications by entering a summary of the member’s concern, options offered by Customer Service to resolve the issue, and any other relevant information. • Maintains the telephone abandonment rate within 1% by working as a team in answering incoming Customer Service telephone lines. • Assists in primary care site transfers by reviewing member requests and providing available options before initiating the transfer process. • Identifies operational issues preventing the delivery of good customer service by documenting and referring these to Customer Service management for follow-up and resolution. • Provides member assistance with bills received from providers by documenting and referring to claims provider bills received by members for services authorized and/or covered by Community Health Group. • Participate in the department’s on-call schedule, weekend and holiday coverage. • Complete “Welcome Calls” within the first two weeks of every month (will require about 10 hours of overtime per month). • Works closely with community based ethnic service and advocacy programs by identifying the member’s/family’s non-medical and social needs and referring these to the appropriate organizations for assistance. • Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested. Education: • Bachelor's Degree Experience/Skills: • Two years of experience in Customer Service (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. • Bilingual English/Spanish, English/Vietnamese, or English/Arabic. • Excellent communication and interpersonal skills. • Ability to exercise mature and independent judgment.