Care Manager


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:

Care Manager

POSITION SUMMARY

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

  • Use effective information gathering strategies that will help to improve the health of our Medicare members and obtain desired results.

  • Conducts home visits for assigned case load.

  • Assists members so they obtain needed STARS/HEDIS related health care services.

  • Collects current phone numbers, email addresses, etc. to help ensure communication with the members.

  • Resolves Medicare member concerns in a timely manner by recommending and facilitating available options.

  • Coordinates urgent care appointments, interpreter services for non-English speaking Medicare members, transportation and prior authorization requests.

  • Gathers information on our Medicare member from a number of different sources (medical, non-medical, home environment, caregiver, family etc). 

  • Work closely with other professionals to coordinate care for our Medicare members (includes medical, behavioral health, social, community-based and other services).

  • Is in constant contact with Medicare members and their families/caregivers to ensure their needs are addressed in the most effective manner.

  • Coordinates and facilitates emergency transfers of site and enrollment verification.

  • Assists in primary care site transfers by reviewing Medicare member requests and providing available options before initiating the transfer process

  • Documents all communications by entering a summary of the Medicare member’s concern, options offered to resolve the issue, and any other relevant information.

  • Meets or exceeds all phone call benchmarks (time to answer call, first call resolution, abandonment rate, etc.).

  • Identifies operational issues preventing the delivery of good customer service by documenting and referring these to management for follow-up and resolution.

  • Refers cases meeting the criteria for grievance classification or plan-initiated disenrollment to management for further follow-up and resolution.

  • Provides assistance with bills received from providers by documenting and referring to Claims department provider bills received by Medicare 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 Medicare 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 in a Health or Human Services Field required (Health Education, Psychology, Sociology, Health Sciences, Public Health, Social Work, Nursing)

     

    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 Medicare populations.

  • Knowledge of Medicare 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.

Ability to secure reliable transportation and possess a valid driver’s license as well as proof of vehicle insurance