Member Navigator
Company: Zencon Group
Location: Wilmington
Posted on: May 28, 2023
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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.
Duties
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
Experience
Required:
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.
Skills
Required:
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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