Customer Relations Specialist- Bilingual Spanish


Community Health Group is a locally based non-profit health plan that ensures access to high quality, culturally sensitive health care for underserved communities throughout San Diego County. We treat our 300-member, multi-lingual staff like family, encouraging an atmosphere of collaborative teamwork, continuous learning, personal growth, and promotion from within. Recognized as one of the Top Workplaces in San Diego, CHG offers its employees such benefits as tuition reimbursement, a meditation room and yoga classes, a monthly Breakfast With The CEO, and memorable events throughout the year. 

We know that by serving our employees well, they, in turn, will better serve our nearly 300,000+ membership. We have been recognized consistently for the excellence and sensitivity of our customer service by members, physicians, vendors, and a full range of health care providers. We are accredited by the National Committee for Quality Assurance and proud of our continuing company-wide Quality Initiatives.

We are currently recruiting for:

Customer Relations Specialist

POSITION SUMMARY

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

  • 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.
  • Works closely with the Customer Service liaison by referring cases meeting the criteria for grievance classification or plan-initiated disenrollment to the Customer Service Liaison for further 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, which includes after business hours, 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
  • Excellent communication and interpersonal skills.
  • Ability to exercise mature and independent judgment.

Physical Requirements:

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