Member Services Navigator III - DSNP - Bilingual Spanish / Job Req 872720193

Member Service Navigator III - DSNP

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 : Under the supervision of the Member Service Supervisor DSNP, a Member Service Navigator III - DSNP will 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. You will act as the primary point of contact for prospective members, and current members / authorized representative, delivering prompt, accurate, and courteous assistance, whether for general inquiries, concerns, or information requests about health care programs, services, eligibility, or benefits. Additionally, the MS Navigator will be cross trained to serve as a Member Service Representative (MSR) or Member Liaison Special BH I (MSR, MLS BH) during periods of high call volume or staffing shortages, ensuring consistent member support and education.

Principal responsibilities include :

• Adhere to established guidelines, call scripts, and resources to address member inquiries, including maintaining the confidentiality of member information and complying with HIPAA and other relevant regulations.
• For non-routine inquiries, leverage available resources and expertise to resolve issues outside standard protocols.
• Know, understand and comply with internal policies and procedures to ensure compliance with CMS Part C Star Ratings Measures (CMS Secret Shopper Calls), DHCS, DMHC and NCQA standards.
• Attend and actively participate in regular departmental meetings, team meetings, training sessions, and coaching sessions as applicable.
• Conduct member outreach such as welcome calls and targeted member outreach calls as assigned.
• Cross training in various tasks as requested to ensure the 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 and prospective members about eligibility, benefits, and our provider network.
• Assist members in selecting or changing their primary care physician (PCP) and provide accurate information about available providers and effective dates for PCP assignments.
• Ensure documentation is accurate and in compliance with regulatory requirements and accreditation standards.
• Handle inbound and outbound calls and other communications in a high-volume environment, providing excellent member service and professionalism following established policies and procedures and meeting performance and quality metrics.
• Intake, handle (first call resolution), and coordinate member grievances, appeals, and claims / billing issues, escalating to the Grievance and Appeals, Pharmacy, or UM department when necessary.
• Maintain health information confidentiality and follow information privacy and security best practices.
• Meet the performance goals established for the position in 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, and with cultural competence; ensure that explanations are appropriate to the member's level of understanding and knowledge.
• Use listening skills and judgment to appropriately categorize and accurately document all interactions and follow-up actions regarding member communications and activities per established guidelines.