Customer Service Navigator ; Spanish

801 Gateway Blvd, South San Francisco, CA 94080, USA

This position will work 100% onsite at 801 Gateway Blvd., South San Francisco, CA

Under direct supervision, respond to HPSM member and provider inquiries by telephone and other communication channels, providing members with comprehensive support regarding health plan benefits and services. Acts as the primary point of contact for members, delivering prompt, accurate, and courteous assistance via telephone and other communication channels, whether for general inquiries, concerns, or information requests about HPSM programs, services, eligibility or benefits.

• Handle inbound and outbound calls and other communications in a high-volume environment, providing excellent customer service and professionalism, in accordance with established policies and procedures, and meeting established performance and quality metrics.
• Adhere to established guidelines, call scripts, and resources to address member and provider inquiries; this includes 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 that fall outside standard protocols or HPSM’s defined scope.
• Resolve concerns accurately, promptly, professionally, and with cultural competence; ensure that explanations are appropriate to the member’s level of understanding and knowledge.
• Intake, handle and coordinate member grievances, appeals and billing issues, escalating to the Grievance and Appeals department, when necessary.
• Educate members and providers about eligibility, benefits, and the HPSM provider network; assist members in selecting or changing their primary care physician and provide accurate information about available providers and effective dates for PCP assignments.
• Use listening skills and judgment to appropriately categorize and accurately document all interactions and follow-up actions regarding member and provider communications and activities in accordance with established guidelines.
• Refer members to appropriate community partner agencies based on their specific needs, including but not limited to Behavioral Health and Recovery Services, Aging and Adult Services, Legal Aid, Human Services Agency, and HICAP when applicable.
• Use strong professional judgement to determine when to elevate member or provider inquiries to other HPSM departments; share important information and collaborate with these teams to resolve issues, this includes referring members to health services for care coordination and guiding providers to specialists for help with complex claims or questions.
• Proactively seek opportunities to improve processes and enhance the overall member experience.
• Attend and actively participate in regular departmental meetings, training sessions, and coaching sessions as applicable.
• Cross train on a variety of tasks as requested, to ensure the continuity of HPSM operations within the Member Services department and other departments.

• Conduct member outreach such as welcome calls and targeted member outreach calls as assigned.
• Participate in and represent HPSM professionally at health fairs, community partnerships, meetings, committees, and coalitions as assigned.
• Perform other duties as assigned.

The following represents the typical way to achieve the necessary skills, knowledge and ability to qualify for this position:

• High school diploma or GED.
• One (1) or more years’ experience in Customer Service or Call Center role, preferably in a health care or public‑sector setting.
• Previous experience with managed care plans, Medi‑Cal and Medicare programs, and working with underserved populations.

• Microsoft Office products including Word, Excel, PowerPoint and Outlook.
• Health insurance and medical terminology.
• Quality metrics relevant to a call center, and best practices for achieving them.

• Bilingual skills in Spanish, Mandarin, Cantonese or Tagalog are preferred but not required.

• Work cooperatively with others.
• Work as part of a…