Apply on Employer Site

L.A. Care Health Plan · 2 days ago

Customer Solution Center Member Navigator II- West Los Angeles Location (Onsite)

Los Angeles, CA

Full-time

Onsite

Entry, Mid Level

$61K/yr - $91K/yr

2+ years exp

L.A. Care Health Plan is the nation’s largest publicly operated health plan, dedicated to providing health coverage to low-income residents of Los Angeles County. The Customer Solution Center Member Navigator II is responsible for resolving member inquiries and coordinating care for complex cases, ensuring member satisfaction and compliance with health plan guidelines.

FitnessGovernmentHealth Care

Responsibilities

Coordinate multi-departmental (Member Services, PNO, Claims, UM, Sales, Medicare enrollment and QM) processes to resolve members 'issues and complex cases to the members' satisfaction. This process may include referrals to plan partners to ensure compliance with regulatory and L. A. Care guidelines. Ensure to follow departmental guidelines/matrixes for all processes. Urgent Complex cases will be handled within 24hrs. All others within 48hrs. (30%)

Work as a navigator to our Medicare Line Of Business (LOB): A. Ensure to meet deadline for completion of Welcome Calls; B. Ensure to follow through on all cases forwarded to other areas for assistance; C. Document all transportation services provided to each member. Ensure to confirm appointment and authorization; D. Coordinate/assist with all other departments regarding Medicare Services; E. Thorough Reinstatement of enrollment of members whose disenrollment are questionable; F. Identify and complete Organization and Coverage Determination for timeliness and resolution; G. Ensure proper Guidelines are followed for Medicare disenrollment request; H. Ensure to complete all BAE and/or LIS request. (25%)

Identify potential quality of care issues and referral to QM Department, through calls received from our Call Center and other internal customers. (10%)

Handle disenrollment's requests from members, providers and plan partners: 1) Long Term Care (Exhaustion of Benefits); 2) Move out of County; 3) Major Organ Transfers; 4) Incarceration; 5) Foster Care. (5%)

Work with Compliance Department regarding suspected fraudulent activities received through the L.A. Care hot line and the Call Center personnel. (5%)

Communicate with collection agencies, billing business offices regarding delinquent and problematic member accounts which includes claims issues from L.A Care Medi-Cal Direct Program (MCLA), Healthy Families (HF), Healthy Kids (HK), and Special Needs Populations (SNP) members. (5%)

Work with Cultural & Linguistic (C&L) to provide translations for members' correspondence into the appropriate languages. As requested review documents submitted by C&L to ensure proper translation and culturally sensitive materials for distribution to our members (brochures pamphlets and educational materials). (5%)

Meet general L.A. Care requirements for attendance and punctuality and follow department guidelines. (5%)

Perform other duties as assigned. (10%)

Qualification

Customer service skillsOral communicationWritten communicationAnalytical skillsMS Office proficiencyConflict resolutionPersuasion skillsMedical terminologyBilingual skills

Required

Associate's Degree

At least 2 years of experience resolving health care eligibility, access, grievance and appeals issues, preferably in health services, legal services and /or public services or public benefits programs with claims and Medicare experience

Strong customer service skills

Excellent oral and written communication skills

Strong analytical and conflict resolutions skills as well as persuasion skills

Proficient in MS Office applications, Word, Excel, Power Point, and Access

Preferred

Bachelor's Degree

Health Plan background a plus along with strong advocacy background

Medical terminology a plus

Bilingual in one of L.A. Care Health Plan's threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese