Member Services Representative I Bilingual Vietnamese - Hybrid Remote

Job Description ATTENTION MILITARY AFFILIATED JOB SEEKERS - Our organization works with partner companies to source qualified talent for their open roles. The following position is available to Veterans, Transitioning Military, National Guard and Reserve Members, and Military Spouses. If you have the required skill set, education requirements, and experience, please click the submit button and follow the next steps.
This position is Hybrid and must be in the Alameda County area.
Member Services Representatives (MSR) are the first point of contact for our members' primary contact with the Alliance for both routine and complex member issues with the goal of delivering excellent customer service to our customers. The position is responsible for answering a high volume of inbound and outbound calls in a timely manner. Respond to all communications coming into Member Services in the form of email, fax, letters, chat and phone calls. Timely responses to all member communication are essential. Must effectively prioritize and flex the workload as new communication and tasks are submitted. Identify the caller's needs, clarify information, research issues, and provide solutions and/or alternatives whenever possible. Accurately and consistently document all conversations in the electronic database. This position is a liaison between the plan, the provider network, and other community agencies. The MSR positions are flexibly staffed classification and work is expected to be performed minimally at the MRS II level. However, the initial selection will be made at the entry level MSR I. Our more advanced level position of the series is the MSR III who will be required to perform a variety of complex matters.

Member Services Representatives are under the direction of a Member Services Supervisor, Manager and Director, and service our members through our call center as well assisting other departments with responses to member issues by initiating communication between departments to ensure action, cooperation, and compliance of managed care operations.

Member Services Representative I

This position which requires the ability to work as a team player within the Alliance and with external contacts, make sound judgments based on analysis of information, be an effective communicator, active listener and balance advocacy for the member with the policy provisions such as plan policies, EOC, regulatory guidelines, and DMHC/DHCS rules and regulations. The MSR provides courteous, professional, and accurate responses to incoming inquiries regarding network, plan benefits, eligibility, authorizations, plan services and guidelines, as well make decisions with the goal of ensuring member satisfaction and retention. The MSR performs a variety of complex functions and is also responsible for maintaining accurate and complete inquiry/grievance records in the electronic database. Maintains compliance with DMHC regulatory requirements and DHCS contractual obligations. MSR I staff who demonstrate proficiency in meeting, maintaining and exceeding principal performance objectives and metrics may be eligible to be promoted to a Member Services II or III role. Member Services Representative I staff may be eligible for promotion to Member Services Representative II or III positions once they have worked as a MSR I for a minimum of 12 months to be proficient with program and system knowledge in addition to meeting performance matrix requirements.

Principle duties and responsibilities

Serve as the primary contact for members, providers and others for questions related to claims, benefits, authorizations, pharmacy, member eligibility and other questions related to Alameda Alliance and provide accurate, satisfactory answers to their inquiries or concerns.
Respond to and resolve member service inquiries and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility, claims, behavioral health, and care
Answer incoming calls, emails, chats, and other requests for assistance in a timely manner in accordance with departmental performance targets and provide excellent customer service while doing so. May include assisting members in
Recognize and understand the difference between calls that require quick resolutions and calls which will require follow-up and handle each
De-escalate situations involving dissatisfied customers, offering patient assistance and support.
Accurately document all contacts per department standards/guidelines in the Customer Relationship Management (CRM)
Accurately and consistently document (electronic database) and resolve Exempt Grievances (any expression of dissatisfaction that are not coverage disputes, disputed health care services involving medical necessity, or experimental or investigational treatment and that are resolved by the next business day following receipt).
Interface with & educate members about the fundamentals and benefits of managed health care topics, to include managing their health & well-being by selecting the best benefit plan service options, maximizing the value of their health plan benefits, & choosing a quality care
Intercede with care providers (doctor's offices) on behalf of the member, assisting with appointment scheduling; connect members with internal Case Management Department for assistance as needed.
Assist members in navigating alamedaalliance.org, the Member Portal, & other health care partner online resources & websites to encourage/reassure them to use self- service tools that are
Manage any issues through to resolution on behalf of the member, either on a single call or through comprehensive & timely follow-up.
Research complex issues across multiple databases & work with support resources to resolve member issues and/or partner with others to resolve escalated
Provide education & status on previously submitted pre-authorizations or pre- determination requests for both medical & pharmaceutical
Meet the performance goals established for the position in the areas of compliance, efficiency, call quality, member satisfaction, first call resolution, punctuality, &
Always maintain a professional level of service to members.
Always maintain confidentiality of information.
Consistently support the Alliance's approach to Service Excellence by adhering to established department & company standards for all work-related functions.
Interact positively with all Alliance
Accurately & consistently document (electronic database) & resolve Exempt Grievances (any expression of dissatisfaction that are not coverage disputes, disputed health care services involving medical necessity, or experimental or investigational treatment & that are resolved by the next business day following receipt).
Process MS Dept projects
Serve as a back-up to manage the escalated calls.
Perform other duties as assigned.
Constant & close visual work at desk or computer.
Constant sitting & working at desk.
Constant data entry using keyboard and/or mouse.
Constant use of multi-monitor setup
Frequent use of telephone and headset.
Frequent verbal & written communication with staff & other business associates by telephone, correspondence, or in person.
Frequent lifting of folders, files, binders, & other objects weighing between 0 and 30 lbs.
Frequent walking and standing.

Salary : $22.00 -$33.01/hr

Certificates/Security Clearances/Other

Bachelor's degree or equivalent experience preferred.
High school diploma, GED required.
The ability to speak and understand-bilingual: Spanish/English, Cantonese/English, Vietnamese/English, Tagalog/English are required as designated.
A bilingual proficiency exam will be administered to ensure the candidate possesses the appropriate skill level to meet requirements. The successful candidate must score 85% or higher.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

Minimum one year of direct customer service Call center experience and managed care experience a plus
Experience determining eligibility for financial assistance, insurance benefits, unemployment and/or other social services programs.
Demonstrated knowledge expert of AAH Member Services policies and procedures
Consistent record of meeting, maintaining, or exceeding monthly Departmental performance metrics.
Consistent track record of documenting Service Requests accurately and clearly and monitoring open Service Requests to ensure responses and
Consistent record of high quality of work as demonstrated through call and documentation auditing, appropriate Call Disposition coding, as well as an overall acceptable monthly Member Satisfaction Survey result as assessed by Member Services Quality Specialist, MS Trainer and Member Services Supervisor.
Demonstrated proficiency in current Customer Relationship Management (CRM) tool, phone system software Quality Management Solution, Pharmacy Benefits Management applications (PBM), Interpreter vendor scheduling software, delegate portal solutions and the Alliance's Member Portal.
Demonstrated ability to effectively handle the department's key special projects: Member Portal Request Processing, Kaiser PTE Requests, PCP retroactive and same month requests.
Demonstrated ability to help members face-to-face in the field and/or at the Alliance offices (walk-ins). Also highly skilled at handling issues related to member bills, transportation set-up and benefit coordination with providers and pharmacy needs.

Additional Qualifications/Responsibilities

Contacts: Receive, manage, and document telephone calls, emails, and other sources of contacts from members, potential members, and providers, and explain health plan benefits and plan rules. Describe the types of services the Alliance offers to the Member within the managed care system. Provide clarification about issues regarding patient and physician rights and how the plan operates.
Conflict resolution: Resolve member problems/conflicts by convening with other departmental staff as needed.
Member communications: Create and/or mail appropriate member materials and communications as needed.
Computer: Perform ongoing data entry which assists in the maintenance of the Member Services department database to ensure data integrity.
Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

Ability to prioritize & adapt to changing situations in a calm & professional manner.
Ability to maintain composure in stressful situations.
Excellent problem-solving skills
Ability to exhibit cooperation, flexibility, & provide assistance when talking to members, providers, & staff.
Skill in basic data entry
Ability to type 40 net words per minute: multi-task
Manual dexterity to operate telephone, computer keyboard equipment.
Speak English proficiently, clearly, and audibly.
Memorize & retain information quickly; meet physical requirements
Spell correctly
Learn the policies, regulations, & rules applicable to business operations.
Follow instructions, reason clearly, analyze solutions accurately, act quickly & effectively in emergency situations; operate office equipment including computers & supporting word processing, spreadsheet, & database applications.
Excellent phone etiquette & ability to communicate clearly & concisely, both orally & in writing.
Excellent interpersonal skills with the ability to interact with diverse individuals & flexibility to customize approach to meet all types of member communication styles & personalities.
Strong verbal & written communication
Demonstrated ability to quickly build rapport & respond to members in a compassionate manner by identifying & exceeding member expectations (responding in respectful, timely manner, consistently meeting commitments).
Demonstrated ability to listen skillfully, collect relevant information, determine immediate requests, & identify the current & future needs of the member.
Must be self-motivated & able to work with minimal supervision
Must be team-oriented & focused on achieving organizational goals
Proficient problem-solving approach to quickly assess current state & formulate recommendations.
Proficient in translating healthcare-related jargon & complex processes into simple, step-by-step instructions which members can understand & act upon.
Proficient conflict management skills to include ability to resolve issues during stressful situations & demonstrating personal
Ability to work regularly scheduled shifts within the Alliance's hours of operation including the training period, with scheduled lunches & breaks, flexibility to adjust daily schedules; & to work over-time and/or weekends as needed.
Medical terminology knowledge preferred
Ability to work within a broad systems perspective
Experience in use of various computer systems software as well as Microsoft Windows, and Microsoft Suite, especially Outlook, Word, Excel.
Must have reliable & stable internet connection for remote work (50-100 Mbps download speeds).