Customer Service Representative ; Spanish Speaking

Overview

Location: 9700 Flair Drive, El Monte, CA 91731

Department: Ops - Member Services

Compensation: $20.00 / hour

Description: Job Title:
Customer Services Representative
Department:
Operations - Member Services

About the Role:

Astrana is looking for a Customer Service Representative to join our fast and growing Dynamic team. This position requires speaking fluent in Spanish.

• Answer all daily telephone calls from members, providers, health plans, insurance brokers, collection agents and hospitals
• Collect Elicit information from members/providers including the problem or concerns and provide general status information
• Verify authorization, claims, eligibility, and status only
• All calls carefully documented into Company’s customer service module & NMM Queue system
• Member/Provider Service/Representative assists Supervisor and Manager with other duties as assigned
• Member outreach communications via mail or telephone
• Assist Member appointment with providers
• Resolve walk-in member concerns
• Able to provide quality service to the customers
• Able to communicate effectively with customers in a professional and respectful manner
• Maintain strictest confidentiality at all times
• Specialist termination notifications sent to members
• Urgent Medicare Authorization Approval – Notification to Medicare members
• Transportation arrangement for Medicare & Medi-Cal members
• Outreach Project Assignments

• INBOUND CALLS:
  • Member/Provider/Health Plan/Vendor/Hospital/Broker:
  • All calls carefully documented into Company’s customer service module
  • Annual Wellness Visit (AWV) – Gift card pick up and schedules
  • Appointment of Representative (AOR) for Medicare Members
  • Attorney / Third Party Vendor calls
  • Authorization status/Modification/Redirection/CPT Code changes/Quantity adds/Explain Denied Auth/Peer to Peer calls/Extend expired auth/Pre-certified auth status/Retro/2ndor 3rd opinion/
  • Conduct 3 way conference call to Health Plan with member
  • Conference call with Providers – Appointments, DME,
  • COVID – 19 related questions (Tests & Vaccines)
  • Direct Member Reimbursement (DMR)
  • Eligibility – Demographic changes:
    Address/Phone/Fax Changes/Name change
  • Escalated calls from providers/members
  • Health Diary Passport
  • Health Source MSO – Assist & arrange inquiries on Eligibility/Change PCP/Benefit with AHMC
  • HIPPA Consent – Obtain Member Consent verification
  • Inquiries on provider network/provider rosters
  • Lab locations
  • Member & Provider Complaints/Grievances
  • Member bills
  • Miscellaneous calls
  • Pharmacy – Drug/medication pick up and coverage
  • Provide authorization status for Hospital /CM Dept
  • Self-Referral Request for Medicare
  • Return Mail
  • Track Mail Packages/ Certified mail status
  • Translations – Spanish / Chinese
  • Urgent Care / locations/ operations hours

• OUTBOUND CALLS:
  • Assist Case Management on CCS – age in 21 years for change of PCP from Pediatrics to FP/IM
  • Assist Marketing on email inquiries
  • Assist PR/ Elig – Members assigned to wrong PCP/with no PCP status
  • Assisted UM / Medical Directors on urgent member appointment from escalated cases
  • Authorization status response call back
  • Benefits – return call once information is obtained / verified
  • Complaints/Grievances – return calls once resolution is obtained
  • DME – Translation support in Spanish and Chinese to confirm item / appointment set up for DME department
  • Eligibility – return call to providers/labs when member is added to system while waiting at the office.
  • Member bills – return calls once resolution is obtained
  • Member Survey – Annually: every 4thquarter
  • Outreach project from internals – QCIT
  • Resolve walk in members concerns
  • Specialist Termination notification sent to members
  • Transportation arrangement for Medicare / Medi-Cal members
  • Voice mail – return calls back to callers

• CONCIERGE SERVICES – ESSENTIAL DUTIES AND REQUIREMENTS:
  • Assist to contact new members/IPA member transfer on new PCP assignment as needed
  • Work group discussions on work status/progress on new member/IPA transfer
  • Update call log and provide daily/weekly status as needed
  • Facilitate members with complex pre-existing conditions, medications, PCP/SPC network reviews
  • Conference call with PCP selection / change
  • Help member to identify member bill status, connect provider with on billing…