Customer Solution Center Member Navigator II- Palmdale ; Onsite

Job Category:
Customer Service

Location:

Los Angeles, CA, US 90017

Position Type:
Full Time

Requisition

Salary Range: $60,778.00 (Min.) – $75,950.00 (Mid.) – $91,166.00 (Max.)

Established in 1997, L​A​ Care Health Plan is an independent public agency created by the state of California to provide health coverage to low‑income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.

Mission: L​A​ Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low‑income communities and residents and to support the safety net required to achieve that purpose.

The Customer Solution Center Member Navigator II is responsible for resolving member inquiries. Coordination of care for complex cases may involve benefit coordination, continuity of care, access to care, quality of care issues, member eligibility, assignment, and disenrollment issues and interpreting requests for all product lines (Medi‑Cal, L​A​ Care Covered, Cal Medi Connect (CMC)). The focus is to provide member satisfaction and handle disenrollment in coordination with U.M. department and Plan Partners:
Department of Health Services (DHS), Centers for Medicare and Medicaid Services (CMS), National Committee Quality Assurance (NCQA), and L​A​ Care guidelines. The Navigator ensures proper handling of member issues presented by members, Ombudsman's, state contractors, member advocates, Executive Community Advisory Committee (ECAC), L​A​ Care Board Members or providers and resolves them 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 processes to ensure identification of members' 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 at designated Community Resource Center/Walk‑In Center and provide support at other locations as needed.

• Coordinate multi‑departmental processes to resolve members' issues and complex cases to members' satisfaction; urgent complex cases within 24 hrs, others within 48 hrs (30%).
• Work as a navigator for Medicare Line of Business (LOB): ensure timely completion of Welcome Calls; follow through all forwarded cases; document all transportation services; confirm appointments and authorizations; coordinate/assist with all Medicare services; reinstate enrollment of members whose disenrollment is questionable; complete Organization and Coverage Determination for timeliness and resolution; ensure proper guidelines are followed for Medicare disenrollment requests; complete all BAE and/or LIS requests (25%).
• Identify potential quality of care issues and refer to QM Department via calls from Call Center and internal customers (10%).
• Handle disenrollment requests from members, providers and plan partners for long‑term care exhaustion, move out of county, major organ transfers, incarceration, and foster care (5%).
• Work with Compliance Department regarding suspected fraudulent activities received through the L​A​ Care hotline and Call Center personnel (5%).
• Communicate with collection agencies and billing business offices regarding delinquent or problematic member accounts, including claims issues from 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 appropriate languages and review documents for proper translation and cultural sensitivity (5%).
• Meet general L​A​ Care requirements for attendance and punctuality and follow department guidelines (5%).
• Perform other duties as assigned (10%).

Associate's Degree

In lieu of degree, equivalent education and/or experience may be considered.

Bachelor's Degree

• Required: At least 2 years of…