Customer Service Representative ; Spanish Speaking

Customer Service Representative I (Spanish Speaking)

Department: Ops - Member Services

Employment Type: Full Time

Location: 9700 Flair Drive, El Monte, CA 91731

Reporting To: Zoey Fu

Compensation: $.00 / hour

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
• HIPAA 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:

Member/Provider/Health Plan/Vendor/Hospital/Broker:

• 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 – ESSENTIALS 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,…