Member Liaison Specialist; Customer Service

Member Liaison Specialist (Customer Service)
Cal Optima Join Us in this Amazing Opportunity

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.

We are hoping you will join us as a Member Liaison Specialist (Customer Service) and help shape the future of healthcare where you'll be an integral part of our CS - Member Liaison team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders.

This position has been approved to be Full Office.

• If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.

The Member Liaison Specialist (Customer Service) will provide member service to seniors, persons with disabilities or chronic conditions, persons without housing and persons under the age of twenty-one (21) who participate in the Whole-Child Model program. You'll serve as a liaison between members, health networks, providers and community-based organizations to facilitate access to services and help resolve health care and psychosocial issues.

Together, we are building a stronger, more equitable health system.

• 85% - Member Support
• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Assesses members' concerns to identify psychosocial or health care issues and facilitate an appropriate resolution.
• Intakes information from members, both over the phone and/or in person, to complete requests for assistance cases, grievances and appeals, per departmental guidelines.
• Coordinates members' health care and social service needs within and outside the health network and Cal Optima Health during the original interaction.
• Addresses member and provider inquiries, questions and concerns in all areas, including enrollment, claims, benefit interpretation, coordination of care and referrals/authorizations for medical care related to services covered under the Whole-Child Model program.
• Guides members in understanding and accessing the benefits under the Whole-Child Model program.
• Maintains documentation of member cases within the FACETS system.
• Initiates referrals to internal and external care management departments and government agencies.
• Communicates with community-based organizations, health networks, providers and vendors on behalf of members to resolve disputes, helps coordinate access to care and investigates issues preventing members from receiving medical benefits and services.
• 10% - Administrative Support
• Collaborates with interdepartmental staff in call resolution as needed.
• Identifies calls needing case management or escalation to a supervisor, manager or director and routes them according to established guidelines.
• Meets all regulatory key performance indicators, first call resolution requirements and business objectives of Cal Optima Health.
• 5% - Other
• Completes other projects and duties as assigned.

• High school diploma or equivalent PLUS 2 years of experience as a call center agent or customer/member services representative in health care required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

• 2 years of experience working with the needs of persons with disabilities and chronic medical conditions in a customer/member service capacity.
• Health…