Position Summary
The Member Care Representative works closely with assigned enrollees to ensure that the quality programs they qualify for are completed.
Essential Responsibilities
Essential Duties and responsibilities include, but are not limited to:
Conducted special program outreach campaigns for assigned members. Program-related categories include, but are not limited to, the following: Categories vary for each Representative.
Initial Health Assessment
Annual Health Assessments
STAR / HEDIS Measures
Risk Adjustment-Related Projects
Maintain a minimum 85 % compliance rate or 4-star equivalent on assigned Star Measures. Potential star measures include, but are not limited to, Measures that 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 and provider offices to guarantee the member receives the care needed.
Coordinate with the 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 an appropriate time frame.
Foster good corporate relations by practicing good customer service principles (i.e., positive attitude, helpfulness, etc.).
Identify challenges, errors, and problems within the processes and ensure follow-up actions are taken to resolve them so that your productivity is not impacted.
Properly document the progress of each assigned member in Cozeva or other related systems.
Report the progress of assigned programs within the appropriate time frame.
Collaborate with QI Department Specialists and Member Care Advocates for campaigns associated with assigned providers.
Escalate physician office and member concerns professionally and ensure that they are addressed.
Perform Data Sweeps to collect medical records from specialists and the PCP office.
Retrieve results and upload them to Cozeva and/or Shared Drive.
Perform other duties and responsibilities assigned by the department director.
Member Care Representatives are required to maintain a minimum of 75-100 daily outbound calls and ensure that all inbound calls are addressed.
Qualifications
Qualifications
To perform this job successfully, an individual must be able to satisfactorily perform each essential duty. The requirements below represent the required knowledge, skill, and/or ability. Reasonable accommodations may be made to enable individuals with disabilities to perform 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 of customer service experience
Health Plan Outreach Experience
Direct member communication, preferably in the Medi-Cal, Commercial, or Medicare Managed Care industry, is 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: Applying common sense understanding to carry out detailed variables in standardized situations.
Computer Skills: Strong computer skills.