Care Advantage Navigator

Bayside Solutions; Oakland (CA); On-site; USD 25,000 - 33,000; Full time

Job summary

Bayside Solutions, Inc. is seeking a CareAdvantage Member Services Specialist in Oakland, CA to serve as the primary contact for CareAdvantage D-SNP and CMC members.

You will assist with all aspects of plan benefits and provide phone-based support for questions about health and prescription drug benefits, eligibility, and provider networks. You will make New Member Welcome Calls, resolve access issues, and document complaints and grievances.

Qualifications

• Equivalent to a high school diploma or GED.
• Two to three years' experience performing customer service, preferably in a health plan environment.
• Experience working with seniors or people with disabilities, and/or in a medically related field such as medical assisting.

Responsibilities

• Provide customer service to CareAdvantage members primarily on the phone.
• Answer member questions about CareAdvantage health and prescription drug benefits, eligibility, and provider network.
• Make New Member Welcome Calls.
• Resolve problems that members have accessing CareAdvantage-covered services.
• Ensure that assigned members retain CareAdvantage enrollment by investigating and contacting members and partnering agencies.
• Clearly document any member's complaints, including grievances and appeals.
• Follow through with proactive solutions to resolve member issues.
• Prepare and submit requests for services made directly by a member to the Health Services.
• Prepare and submit member requests for continuity of care with non-contracted providers to the Provider Services Department.
• Refer members to appropriate community partner agencies depending on specific circumstances, including but not limited to: Behavioral Health and Recovery Services, Aging and Adult Services, Legal Aid, and/or HICAP when appropriate.
• Relay pertinent health information to the clinical staff to facilitate care coordination and/or receipt of medical services, including prescriptions.
• Participate in and professionally represent us at health fairs, community partnerships, meetings, committees, and coalitions as requested by the Manager or Supervisor.

Skills

Customer service

Healthcare plan experience

Medicare/Medi-Cal knowledge

Benefits navigation

Phone support

Documenting complaints

Education

High school diploma or GED

Tools

Microsoft Office

Job description

Act as the primary point of contact for members of CareAdvantage D-SNP and CareAdvantage CMC and assist members with all aspects of plan benefits.

Duties and Responsibilities:

• Provide customer service to CareAdvantage members primarily on the phone.
• Answer member questions about CareAdvantage health and prescription drug benefits, eligibility, and provider network.
• Make New Member Welcome Calls.
• Resolve problems that members have accessing CareAdvantage-covered services, including but not limited to health care services and prescription medications.
• Ensure that assigned members retain CareAdvantage enrollment by investigating and contacting members and partnering agencies.
• Clearly document any member's complaints, including grievances and appeals.
• Follow through with proactive solutions to resolve member issues.
• Prepare and submit requests for services made directly by a member to the Health Services.
• Prepare and submit member requests for continuity of care with non-contracted providers to the Provider Services Department.
• Refer members to appropriate community partner agencies depending on specific circumstances, including but not limited to: Behavioral Health and Recovery Services, Aging and Adult Services, Legal Aid, and/or HICAP when appropriate.
• Relay pertinent health information to the clinical staff to facilitate care coordination and/or receipt of medical services, including prescriptions.
• Participate in and professionally represent us at health fairs, community partnerships, meetings, committees, and coalitions as requested by the Manager or Supervisor.

Requirements and Qualifications:

• Equivalent to a high school diploma or GED required.
• Two (2) to three (3) years' experience performing customer service, preferably in a health plan environment.
• Previous experience working with seniors or people with disabilities, and/or in a medically related field such as medical assisting.
• Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access, and PowerPoint.
• Health Insurance programs preferred.
• Customer service principles and practices.

Desired Skills and Experience

Customer Service, Member Services, Health Plan Benefits, Medicare, Medi-Cal, Dual Eligible Special Needs Plans (D-SNP), Prescription Drug Benefits, Eligibility Verification, Provider Networks, Member Outreach, Welcome Calls, Enrollment Retention, Benefits Navigation, Issue Resolution, Grievances and Appeals, Complaint Documentation, Service Requests, Continuity of Care, Care Coordination, Community Resource Referrals, Behavioral Health Services, Senior Services, Disability Services, Health Insurance, Medical Terminology, Telephone Support, Microsoft Office Suite, Outlook, Word, Excel, Access, PowerPoint

Bayside Solutions, Inc. is not able to sponsor any candidates at this time. Additionally, candidates for this position must qualify as a W2 candidate.

Bayside Solutions, Inc. may collect your personal information during the position application process. Please reference Bayside Solutions, Inc.'s CCPA Privacy Policy at www.baysidesolutions.com.