Member Services Representative - Bilingual Farsi​/Req

Hybrid positions work a minimum of up to 2 days per week in Alameda Alliance for Health’s office located in Alameda CA, and a minimum of three days per week remotely. Full‑time must live in one of 6 states: CA, AZ, NV, TX, WA, OR; remote and on site in Alameda County. Available for full‑time work schedule 8:00 am – 5:00 pm Pacific Time, Monday‑Friday.

This role serves as the first point of contact for members, handling routine and complex issues, managing inbound/outbound calls, emails, chat, fax, and other communications. Duties include prioritizing workload, clarifying information, providing solutions, documenting interactions in the electronic database, and liaising with providers, the plan, and community agencies.

• Serve as the primary contact for members, providers and others for questions related to claims, benefits, authorizations, pharmacy, member eligibility and other questions related to Alameda Alliance and provide accurate, satisfactory answers to their inquiries or concerns.
• Respond to and resolve member service inquiries and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility, claims, behavioral health, and care coordination.
• Answer incoming calls, emails, chats, and other requests for assistance in a timely manner in accordance with departmental performance targets and provide excellent customer service while doing so. May include assisting members in person.
• Recognize and understand the difference between calls that require quick resolutions and calls which will require follow‑up and handle each appropriately.
• De‑escalate situations involving dissatisfied customers, offering patient assistance and support.
• Accurately document all contacts per department standards/guidelines in the Customer Relationship Management (CRM) system.
• Accurately and consistently document and resolve exempt grievances and other member concerns.
• Interface with Grievance and Appeals, Claims, Enrollment, IT, Network Management, Pharmacy, Authorizations, and other internal departments to provide Service Excellence to our members.
• Help guide and educate members about the fundamentals and benefits of managed health care topics, to include managing their health and well‑being by selecting the best benefit plan service options, maximizing the value of their health plan benefits, and choosing a quality care provider.
• Intercede with care providers (doctor’s offices) on behalf of the member, assisting with appointment scheduling; connect members with internal Case Management Department for assistance as needed.
• Assist members in navigating alamedaalliance.org, the Member Portal, and other health care partner online resources and websites to encourage/reassure them to use self‑service tools that are available.
• Manage any issues through to resolution on behalf of the member, either on a single call or through comprehensive and timely follow‑up.
• Research complex issues across multiple databases and work with support resources to resolve member issues and/or partner with others to resolve escalated issues.
• Provide education and status on previously submitted pre‑authorizations or pre‑determination requests for both medical and pharmaceutical benefits.
• Meet the performance goals established for the position in the areas of compliance, efficiency, call quality, member satisfaction, first call resolution, punctuality, and attendance.
• Always maintain a professional level of service to members.
• Always maintain confidentiality of information.
• Consistently support the Alliance’s approach to Service Excellence by adhering to established department and company standards for all work‑related functions.
• Interact positively with all Alliance Departments.
• Process MS Dept projects.
• Serve as a back‑up to manage the escalated calls.
• Perform other duties as assigned.

• Contacts:
  Receive, manage, and document telephone calls, emails, and other sources of contacts from members, potential members, and providers, and explain health plan benefits and plan rules. Describe the types of services the Alliance offers to the Member within the managed care system. Provide…