Member Services Navigator III - DSNP - Bilingual Spanish / Job Req 872720193
SelectTech Services Corp, California, MO, United States
Onsite
Full Time Onsite 1240 South Loop Road, Alameda, California. Applicants must be a California resident as of their first day of employment.
Principal Responsibilities
Respond to health plan member inquiries by telephone and other communication channels, providing members or prospective members with comprehensive support regarding health plan benefits and services.
Act as the primary point of contact for prospective members, and current members/authorized representative, delivering prompt, accurate, and courteous assistance for general inquiries, concerns, or information requests about health care programs, services, eligibility, or benefits.
Cross‑train to serve as a Member Service Representative (MSR) or Member Liaison Special BH I during periods of high call volume or staffing shortages, ensuring consistent member support and education.
Adhere to established guidelines, call scripts, and resources to address member inquiries, maintaining confidentiality of member information and complying with HIPAA and other regulations.
Know, understand, and comply with internal policies and procedures to ensure compliance with CMS Part C Star Ratings Measures, DHCS, DMHC, and NCQA standards; attend regular departmental meetings, training, and coaching sessions.
Conduct member outreach such as welcome calls and targeted member outreach calls as assigned.
Cross‑train in various tasks to ensure continuity of operations within the Member Services department and other departments.
Develop and proactively maintain up‑to‑date knowledge of relevant quality, regulatory, and organizational guidelines.
Educate members about eligibility, benefits, and the provider network; assist members in selecting or changing their primary care physician and provide accurate information about available providers and effective dates.
Ensure documentation is accurate and meets regulatory requirements and accreditation standards.
Handle inbound and outbound calls in a high‑volume environment, providing excellent member service and professionalism and meeting performance and quality metrics.
Intake, handle (first call resolution), and coordinate member grievances, appeals, and claims/billing issues, escalating to the appropriate departments when necessary.
Maintain health information confidentiality and follow best practices for privacy and security.
Meet performance goals for efficiency, call quality, member satisfaction, first call resolution, punctuality, compliance, and attendance.
Participate in and represent the company professionally at health fairs, community partnership meetings, committees, and coalitions.
Perform problem research, use analytical skills, and effectively influence positive outcomes.
Proactively seek opportunities to improve processes and enhance the overall member experience.
Resolve concerns accurately, promptly, professionally, with cultural competence; ensure explanations are appropriate to the member’s level of understanding.
Use listening skills and judgment to categorize and document all member interactions and follow‑up actions per guidelines.
Apply professional judgment to determine when to elevate inquiries; collaborate with teams to resolve issues and refer members to health services, providers, or community partner agencies as appropriate.
Maintain knowledge of desk‑level procedures and stay updated with training materials to meet departmental standards.
Understand case‑type expectations for care coordination, complex cases, and transitions of care.
When appropriate, work with state and federal eligibility and enrollment staff/vendors to assist in enrollment continuity.
Guide members about maximizing health plan benefits and choosing a primary care provider.
Contact care providers on behalf of members to assist with appointment scheduling or internal assistance.
Assist members navigating the AAH website, encouraging and reassuring them.
Assist members in person.
Complete other duties and special projects as assigned.
Maintain adequate passing score on monthly productivity audits for call volume and documentation volume.
Demonstrate availability to accept incoming calls during normal business hours unless approved by leadership.
Maintain adequate passing score (95%) on monthly audits for quality and accuracy.
Maintain adequate passing score (95%) on monthly compliance audits.
Maintain adequate passing score on monthly attendance and punctuality audits.
Essential Functions of the Job
Telephone: complete and document all telephone calls and explain health plan program benefits to Alliance members.
Computer: accurately maintain member database to ensure data integrity.
Meetings: participate in departmental and non‑departmental meetings and other scenarios.
Write, administer, enter data, analyze, and prepare reports.
Comply with Code of Conduct, regulatory, contractual, and internal control requirements.
Maintain adaptability and flexibility; engage in cross‑training to acquire skills for various responsibilities.
Apply cross‑training methods to minimize call transfers and escalations, supporting resolution during initial contact.
Serve as main contact across several Alliance Member Services channels: phone queues, in‑person engagements, mail, email, and online portal.
Respond to inquiries by providing precise information about Alliance plans, benefits, eligibility, and enrollment procedures.
Manage concerns and complaints, resolving complex member issues and de‑escalating challenging situations, following guidelines while maintaining customer service standards.
Investigate complex issues and ensure resolution.
Exhibit thorough understanding of coverage and benefits to support appropriate service usage per DHCS, DMHC, CMS, NCQA guidelines.
Attend required departmental and non‑departmental meetings.
Present information about Alliance and community partner services clearly and respectfully.
Follow AAH policies and procedures and adhere to DMHC, DHCS, CMS, NCQA regulations, including PHI/HIPAA compliance.
Develop solutions to challenges and opportunities as they arise.
Remain informed about available health plans and AAH benefits.
Communicate verbally and in writing effectively with diverse audiences.
Physical Requirements
Constant close visual work at a desk or computer.
Constant sitting at a desk.
Constant data entry using multiple monitors, keyboard, and/or mouse.
Frequent use of telephone headset.
Frequent verbal and written communication with staff and business associates by phone, correspondence, or in person.
Frequent lifting of files, binders, and other objects weighing 0‑30 lbs.
Frequent walking and standing.
Education or Training Equivalent To
High School Diploma or GED required.
Bachelor’s degree or combination of education and experience may qualify.
Two years of experience in behavioral health, community services, or other social services setting required.
Experience working with children diagnosed with ASD or ABA services preferred.
Customer service: call center experience preferred.
Experience in Managed Care, HMO, Medi‑Cal/Medicare, and health services preferred.
Minimum Years of Additional Related Experience
One year of experience in triage, intake, or care coordination.
Two years of experience in Customer Service or call‑center role, member‑facing, preferably in a health care or public‑sector setting.
Two years’ recent experience with managed care plans, Medi‑Cal, Medicare, and serving underserved populations.
Special Qualifications (Skills, Abilities, License)
Ability to speak and understand bilingual: Spanish/English, Cantonese/English, Mandarin/English, Vietnamese/English, Tagalog/English, Arabic/English, Farsi/English as required.
Must score 90% or higher on bilingual proficiency exam.
Fluency and proficiency in English.
Proficiency in correct English usage, grammar, and punctuation.
Demonstrated telephone etiquette and patience.
Ability to communicate and collaborate with a variety of providers and individuals.
Preferred experience working with individuals with complex health needs.
Preferred experience with de‑escalation techniques.
Preferred completion of AHIP's Medicare + Fraud, Waste, and Abuse training.
Preferred experience in crisis intervention and mental health services.
Experience in Utilization Management, Case Management, Care Coordination, or Telephonic Case Management beneficial.
Familiarity with state and federal insurance programs advantageous.
Knowledge of Alameda County community resources, Medicare, Medi‑Cal, HICAP, Health Care Options, and Social Services.
Basic understanding of medical concepts, chronic disease conditions, and common treatment options.
Experience triaging crisis calls and escalating as necessary.
Ability to work assigned shifts during Alliance operating hours, including training period, and flexibility for overtime and weekend work.
Experience assessing callers’ needs and directing them to appropriate individuals or departments.
Strong computer and typing proficiency; proficient in Windows and Microsoft Office suite.
Knowledge of health insurance and medical terminology, call‑center best practices, and quality metrics.
Good analytical and interpretive skills.
Strong organizational skills, proactive and detail oriented.
Sensitivity to a diverse, low‑income community.
Excellent critical‑thinking and problem‑solving skills.
Ability to act as a resource.
Excellent presentation, customer service and delivery skills.
Experience supporting members enrolled in Medicare Advantage plans for dual‑eligible individuals.
Demonstrated understanding of complex medical and insurance policies related to dual eligibility.
Outstanding service in identifying and resolving caller issues in a timely, professional manner.
Familiarity with Alameda County resources a plus.
Familiar with quality metrics relevant to a call center and best practices to achieve them.
Ability to prioritize and adapt to changing situations calmly and professionally.
Ability to maintain composure in stressful situations.
Typing speed 40 net words per minute; multitasking.
Demonstrated ability to listen skillfully, collect relevant information, determine immediate requests, and identify current and future needs of members.
Self‑motivated and able to work with minimal supervision.
Team‑oriented and focused on achieving organizational goals.
Proficient in translating healthcare jargon into simple instructions for members.
Proficient conflict‑management skills to resolve issues during stressful situations.
Salary Range
$30.26 - $45.40 hourly.
EEO Statement
The Alliance is an equal opportunity employer and makes all employment decisions on the basis of merit and business necessity. The Alliance prohibits unlawful discrimination against any employee or applicant for employment based on race, color, religious creed, sex, gender, transgender status, age, sexual orientation, national origin, ethnicity, citizenship, ancestry, religion, marital status, familial status, status as a victim of domestic violence, assault or stalking, military service/veteran status, physical or mental disability, genetic information, medical condition, employees requesting accommodation of a disability or religious belief, political affiliation or activities, or any other status protected by federal, state, or local laws.
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Full Time Onsite 1240 South Loop Road, Alameda, California. Applicants must be a California resident as of their first day of employment.
Principal Responsibilities
Respond to health plan member inquiries by telephone and other communication channels, providing members or prospective members with comprehensive support regarding health plan benefits and services.
Act as the primary point of contact for prospective members, and current members/authorized representative, delivering prompt, accurate, and courteous assistance for general inquiries, concerns, or information requests about health care programs, services, eligibility, or benefits.
Cross‑train to serve as a Member Service Representative (MSR) or Member Liaison Special BH I during periods of high call volume or staffing shortages, ensuring consistent member support and education.
Adhere to established guidelines, call scripts, and resources to address member inquiries, maintaining confidentiality of member information and complying with HIPAA and other regulations.
Know, understand, and comply with internal policies and procedures to ensure compliance with CMS Part C Star Ratings Measures, DHCS, DMHC, and NCQA standards; attend regular departmental meetings, training, and coaching sessions.
Conduct member outreach such as welcome calls and targeted member outreach calls as assigned.
Cross‑train in various tasks to ensure continuity of operations within the Member Services department and other departments.
Develop and proactively maintain up‑to‑date knowledge of relevant quality, regulatory, and organizational guidelines.
Educate members about eligibility, benefits, and the provider network; assist members in selecting or changing their primary care physician and provide accurate information about available providers and effective dates.
Ensure documentation is accurate and meets regulatory requirements and accreditation standards.
Handle inbound and outbound calls in a high‑volume environment, providing excellent member service and professionalism and meeting performance and quality metrics.
Intake, handle (first call resolution), and coordinate member grievances, appeals, and claims/billing issues, escalating to the appropriate departments when necessary.
Maintain health information confidentiality and follow best practices for privacy and security.
Meet performance goals for efficiency, call quality, member satisfaction, first call resolution, punctuality, compliance, and attendance.
Participate in and represent the company professionally at health fairs, community partnership meetings, committees, and coalitions.
Perform problem research, use analytical skills, and effectively influence positive outcomes.
Proactively seek opportunities to improve processes and enhance the overall member experience.
Resolve concerns accurately, promptly, professionally, with cultural competence; ensure explanations are appropriate to the member’s level of understanding.
Use listening skills and judgment to categorize and document all member interactions and follow‑up actions per guidelines.
Apply professional judgment to determine when to elevate inquiries; collaborate with teams to resolve issues and refer members to health services, providers, or community partner agencies as appropriate.
Maintain knowledge of desk‑level procedures and stay updated with training materials to meet departmental standards.
Understand case‑type expectations for care coordination, complex cases, and transitions of care.
When appropriate, work with state and federal eligibility and enrollment staff/vendors to assist in enrollment continuity.
Guide members about maximizing health plan benefits and choosing a primary care provider.
Contact care providers on behalf of members to assist with appointment scheduling or internal assistance.
Assist members navigating the AAH website, encouraging and reassuring them.
Assist members in person.
Complete other duties and special projects as assigned.
Maintain adequate passing score on monthly productivity audits for call volume and documentation volume.
Demonstrate availability to accept incoming calls during normal business hours unless approved by leadership.
Maintain adequate passing score (95%) on monthly audits for quality and accuracy.
Maintain adequate passing score (95%) on monthly compliance audits.
Maintain adequate passing score on monthly attendance and punctuality audits.
Essential Functions of the Job
Telephone: complete and document all telephone calls and explain health plan program benefits to Alliance members.
Computer: accurately maintain member database to ensure data integrity.
Meetings: participate in departmental and non‑departmental meetings and other scenarios.
Write, administer, enter data, analyze, and prepare reports.
Comply with Code of Conduct, regulatory, contractual, and internal control requirements.
Maintain adaptability and flexibility; engage in cross‑training to acquire skills for various responsibilities.
Apply cross‑training methods to minimize call transfers and escalations, supporting resolution during initial contact.
Serve as main contact across several Alliance Member Services channels: phone queues, in‑person engagements, mail, email, and online portal.
Respond to inquiries by providing precise information about Alliance plans, benefits, eligibility, and enrollment procedures.
Manage concerns and complaints, resolving complex member issues and de‑escalating challenging situations, following guidelines while maintaining customer service standards.
Investigate complex issues and ensure resolution.
Exhibit thorough understanding of coverage and benefits to support appropriate service usage per DHCS, DMHC, CMS, NCQA guidelines.
Attend required departmental and non‑departmental meetings.
Present information about Alliance and community partner services clearly and respectfully.
Follow AAH policies and procedures and adhere to DMHC, DHCS, CMS, NCQA regulations, including PHI/HIPAA compliance.
Develop solutions to challenges and opportunities as they arise.
Remain informed about available health plans and AAH benefits.
Communicate verbally and in writing effectively with diverse audiences.
Physical Requirements
Constant close visual work at a desk or computer.
Constant sitting at a desk.
Constant data entry using multiple monitors, keyboard, and/or mouse.
Frequent use of telephone headset.
Frequent verbal and written communication with staff and business associates by phone, correspondence, or in person.
Frequent lifting of files, binders, and other objects weighing 0‑30 lbs.
Frequent walking and standing.
Education or Training Equivalent To
High School Diploma or GED required.
Bachelor’s degree or combination of education and experience may qualify.
Two years of experience in behavioral health, community services, or other social services setting required.
Experience working with children diagnosed with ASD or ABA services preferred.
Customer service: call center experience preferred.
Experience in Managed Care, HMO, Medi‑Cal/Medicare, and health services preferred.
Minimum Years of Additional Related Experience
One year of experience in triage, intake, or care coordination.
Two years of experience in Customer Service or call‑center role, member‑facing, preferably in a health care or public‑sector setting.
Two years’ recent experience with managed care plans, Medi‑Cal, Medicare, and serving underserved populations.
Special Qualifications (Skills, Abilities, License)
Ability to speak and understand bilingual: Spanish/English, Cantonese/English, Mandarin/English, Vietnamese/English, Tagalog/English, Arabic/English, Farsi/English as required.
Must score 90% or higher on bilingual proficiency exam.
Fluency and proficiency in English.
Proficiency in correct English usage, grammar, and punctuation.
Demonstrated telephone etiquette and patience.
Ability to communicate and collaborate with a variety of providers and individuals.
Preferred experience working with individuals with complex health needs.
Preferred experience with de‑escalation techniques.
Preferred completion of AHIP's Medicare + Fraud, Waste, and Abuse training.
Preferred experience in crisis intervention and mental health services.
Experience in Utilization Management, Case Management, Care Coordination, or Telephonic Case Management beneficial.
Familiarity with state and federal insurance programs advantageous.
Knowledge of Alameda County community resources, Medicare, Medi‑Cal, HICAP, Health Care Options, and Social Services.
Basic understanding of medical concepts, chronic disease conditions, and common treatment options.
Experience triaging crisis calls and escalating as necessary.
Ability to work assigned shifts during Alliance operating hours, including training period, and flexibility for overtime and weekend work.
Experience assessing callers’ needs and directing them to appropriate individuals or departments.
Strong computer and typing proficiency; proficient in Windows and Microsoft Office suite.
Knowledge of health insurance and medical terminology, call‑center best practices, and quality metrics.
Good analytical and interpretive skills.
Strong organizational skills, proactive and detail oriented.
Sensitivity to a diverse, low‑income community.
Excellent critical‑thinking and problem‑solving skills.
Ability to act as a resource.
Excellent presentation, customer service and delivery skills.
Experience supporting members enrolled in Medicare Advantage plans for dual‑eligible individuals.
Demonstrated understanding of complex medical and insurance policies related to dual eligibility.
Outstanding service in identifying and resolving caller issues in a timely, professional manner.
Familiarity with Alameda County resources a plus.
Familiar with quality metrics relevant to a call center and best practices to achieve them.
Ability to prioritize and adapt to changing situations calmly and professionally.
Ability to maintain composure in stressful situations.
Typing speed 40 net words per minute; multitasking.
Demonstrated ability to listen skillfully, collect relevant information, determine immediate requests, and identify current and future needs of members.
Self‑motivated and able to work with minimal supervision.
Team‑oriented and focused on achieving organizational goals.
Proficient in translating healthcare jargon into simple instructions for members.
Proficient conflict‑management skills to resolve issues during stressful situations.
Salary Range
$30.26 - $45.40 hourly.
EEO Statement
The Alliance is an equal opportunity employer and makes all employment decisions on the basis of merit and business necessity. The Alliance prohibits unlawful discrimination against any employee or applicant for employment based on race, color, religious creed, sex, gender, transgender status, age, sexual orientation, national origin, ethnicity, citizenship, ancestry, religion, marital status, familial status, status as a victim of domestic violence, assault or stalking, military service/veteran status, physical or mental disability, genetic information, medical condition, employees requesting accommodation of a disability or religious belief, political affiliation or activities, or any other status protected by federal, state, or local laws.
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