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Member Navigator

Company: Zencon Group
Location: Wilmington
Posted on: May 28, 2023

Job Description:

Job Description

Job Summary

The Customer Solution Center Member Navigator II is responsible for resolving member inquiries. Coordination of care for complex cases which may involve benefit coordination, continuity of care, access to care, quality of care issues, member eligibility, assignment, disenrollment's issues and interpreting requests for all product lines (Medi-Cal, L.A. Care Covered, Cal MediConnect (CMC)). It will be expected that the main focus is to provide member satisfaction. In addition, this position is responsible for handling disenrollment's in coordination with U.M. department and Plan Partners: Department of Health Services (Client), Centers for Medicare and Medicaid Services (CMS) National Committee Quality Assurance (NCQA) as well as L.A. Care guidelines. The Navigator ensures the proper handling of member issues whether presented by members, the Ombudsman's, state contractors, member advocates, Executive Community Advisory Committee (ECAC), L.A. Care Board Members or providers are resolved expeditiously. The Navigator handles and coordinates the identification, documentation, investigation and resolution of complex cases, in a timely and culturally-appropriate manner. Coordinates multi-departmental (Member Services, Product Network Operations (PNO), Claims, Utilization Management (UM), Pharmacy, Medicare Enrollment/Disenrollment, Sales and Quality Management (QM)) processes to ensure identification of member's claims of gaps in coverage and resolution of cases for members' satisfaction and of referral cases to plan partners when applicable. The Navigator will be stationed and available to assist our members at any of our designated Community Resource Center/Walk-In Center. Will provide Navigator support at other Community Resources Center locations as needed.


Coordinate multi-departmental (Member Services, PNO , Claims, UM, Sales, Medicare enrollment and QM) processes to resolve members 'issues and complex cases to the members' satisfaction. This process may include referrals to plan partners to ensure compliance with regulatory and L. A. Care guidelines. Ensure to follow departmental guidelines/matrixes for all processes. Urgent Complex cases will be handled within 24hrs. All others within 48hrs. (30%)Work as a navigator to our Medicare Line Of Business (LOB): A. Ensure to meet deadline for completion of Welcome Calls; B. Ensure to follow through on all cases forwarded to other areas for assistance; C. Document all transportation services provided to each member. Ensure to confirm appointment and authorization; D. Coordinate/assist with all other departments regarding Medicare Services; E. Thorough Reinstatement of enrollment of members whose disenrollment are questionable; F. Identify and complete Organization and Coverage Determination for timeliness and resolution; G. Ensure proper Guidelines are followed for Medicare disenrollment request; H. Ensure to complete all BAE and/or LIS request. (25%)Identify potential quality of care issues and referral to QM Department, through calls received from our Call Center and other internal customers. (10%)Handle disenrollment's requests from and members, providers and plan partners: 1) Long Term Care ( Exhaustion of Benefits); 2) Move out of County; 3) Major Organ Transfers; 4) Incarceration; 5) Foster Care. (5%)Work with Compliance Department regarding suspected fraudulent activities received through the L.A. Care hot line and the Call Center personnel. (5%)Communicate with collection agencies, billing business offices regarding delinquent and problematic member accounts which includes claims issues from L.A Care Medi-Cal Direct Program (MCLA), Healthy Families (HF), Healthy Kids (HK), and Special Needs Populations (SNP) members. (5%)Work with Cultural & Linguistic (C&L) to provide translations for members' correspondence into the appropriate languages. As requested review documents submitted by C&L to ensure proper translation and culturally sensitive materials for distribution to our members (brochures pamphlets and educational materials). (5%)Meet general L.A. Care requirements for attendance and punctuality and follow department guidelines. (5%)Perform other duties as assigned. (10%)

Duties Continued

Education Required

ssociate's DegreeIn lieu of degree, equivalent education and/or experience may be considered.

Education Preferred

Bachelor's Degree


At least 0-2 years experience resolving health care eligibility, access, grievance and appeals issues, preferably in health services, legal services and /or public services or public benefits programs with claims and Medicare experience. Health Plan background a plus along with strong advocacy background.


Strong customer service skills. Excellent oral and written communication skills. Strong analytical and conflict resolutions skills as well as persuasion skills. Proficient in MS Office applications, Word, Excel, Power Point, and Access. Preferred:
Medical terminology a plus. Bilingual in one of L.A. Care Health Plan's threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.

Keywords: Zencon Group, Los Angeles , Member Navigator, Other , Wilmington, California

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