Position Summary
The Member Care Representative works closely with assigned enrollees to ensure that the quality programs they qualify
for are completed. You will have 30/60/90-day evaluations to determine if the essential duties and responsibilities are
being met and if you have passed the 90-day probationary period.
Essential Responsibilities
Essential Duties and responsibilities include, but are not limited to:
Conduct special program outreach campaigns to assigned members. Programs related categories are as follow, but no limited to: Categories vary for each Representative.
Initial Health Assessment
Annual Health Assessments
STAR / HEDIS Measures
Maintain a minimum 85 % compliance rate or 4-star equivalent on assigned Star Measures. Potential star measures are as follows, but not limited to: Measures could vary for each Representative.
Breast Cancer Screening
Colon Cancer Screening
COA – Medication Review and List
COA- Pain Screening
HBA1C
Diabetic Eye Screening
MRPD
KED
CBP
OMW
Make all attempts to assist members in obtaining required care and coordinate with assigned team members,provider offices to guarantee the member receives the care needed.
Coordinate with field team to ensure member home visits are completed to comply with campaign goals.
Ensure daily outreach call goals are met per campaign.
Use systems such as Office @ hand, Five9, Cozeva, Outlook and Excel as advised.
Collaborate and Coordinate with QI department team members to complete all outreaches in appropriate time frame.
Foster good corporate relations by practicing good customer service principles (i.e., positive attitude, helpful, etc.).
Identify challenges, errors, problems within the processes and ensure follow-up actions are taken to resolve the matter so that your productivity is not impacted.
Properly document the progress of each assigned member in Cozeva or other related systems.
Report progress of assigned programs within appropriate time frame.
Collaborate with QI Department Specialist and Member Care Advocates for campaigns associated to assigned providers.
Escalate physician office and member concerns in a professional fashion and ensure that they are addressed.
Perform Data Sweeps to collect medical records from specialist and PCP office.
Retrieve results and upload to Cozeva and/or Shared drive.
Perform other duties and responsibilities assigned by department director.
Member Care Representative are required to maintain a minimum of 50-60 daily outbound call minimum and
ensure that all inbound calls are addressed.
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience: High School or general education degree (GED); or on to three months related experience and/or training; or equivalent combination of education and experience.
Medical Assistance Certificate: Not required but preferred.
Phlebotomy License: Preferred but not required.
Other Qualifications:
Two years customer service experience
Health Plan Outreach Experience
Direct member communication, preferably in the Medi-Cal, Commercial, or Medicare Managed Care industry preferred.
Knowledge of Medi-Cal, Commercial, and Medicare Managed Care Plans preferred.
Bilingual (English/Spanish) required.
Skills and Abilities
Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization.
Mathematical Skills: Ability to add and subtract two-digit numbers and to multiply and divide with 10s and 100s. Ability to perform these operations using units of American money and weight measurement, volume and distance.
Reasoning Skills: Ability to apply common sense understanding to carry out detailed but variables in standardized situations.
Computer Skills: Strong computer skills