Case Manager I

Community Health Group; Chula Vista (CA); On-site; USD 79,000 - 91,000; Full time

Job summary

Community Health Group seeks a dedicated Customer Service/Case Manager to enhance Medicare member satisfaction from our Corporate Headquarters in Chula Vista, CA. The role collaborates with multiple departments to respond to member concerns and coordinate needed services.

You will conduct home visits, help members access STARS/HEDIS services, gather contact information, and ensure timely resolution of issues while occasionally traveling within San Diego County.

Qualifications

• Bachelor’s degree in health or human services required.
• Two years of customer service experience preferred.
• Bilingual abilities and sensitivity to cultural needs are valued.

Responsibilities

• Gather information to improve Medicare member health outcomes.
• Conduct home visits for assigned case load.
• Assist members in obtaining STARS/HEDIS related services.
• Contact members via phone/email and coordinate care options.
• Resolve Medicare member concerns in a timely manner.
• Coordinate urgent care, interpreter services, transportation, and prior authorizations.

Skills

Customer service

Communication skills

Bilingual (English/Spanish)

Independent judgment

Driver's license

Education

Bachelor's degree in Health or Human Services

Job description

Job Details

Job Location: Corporate Headquarters - Chula Vista, CA 91914

Position Type: Full Time

Salary Range: $79,056.81 - $90,915.33 Salary

Position Summary

Drives customer loyalty and provides excellent customer service to our customers (Medicare members and providers). This position will work with other departments in order to respond to Medicare member concerns in a timely manner.

Compliance with Regulations

Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D, DHCS and DMHC.

Responsibilities

• Use effective information gathering strategies that will help to improve the health of our Medicare members and obtain desired results.


• Conducts home visits for assigned case load.


• Assists members so they obtain needed STARS/HEDIS related health care services.


• Collects current phone numbers, email addresses, etc. to help ensure communication with the members.


• Resolves Medicare member concerns in a timely manner by recommending and facilitating available options.


• Coordinates urgent care appointments, interpreter services for non-English speaking Medicare members, transportation and prior authorization requests.


• Gathers information on our Medicare member from a number of different sources (medical, non-medical, home environment, caregiver, family etc).


• Work closely with other professionals to coordinate care for our Medicare members (includes medical, behavioral health, social, community-based and other services).


• Is in constant contact with Medicare members and their families/caregivers to ensure their needs are addressed in the most effective manner.


• Coordinates and facilitates emergency transfers of site and enrollment verification.


• Assists in primary care site transfers by reviewing Medicare member requests and providing available options before initiating the transfer process.


• Documents all communications by entering a summary of the Medicare member’s concern, options offered to resolve the issue, and any other relevant information.


• Meets or exceeds all phone call benchmarks (time to answer call, first call resolution, abandonment rate, etc.).


• Identifies operational issues preventing the delivery of good customer service by documenting and referring these to management for follow-up and resolution.


• Refers cases meeting the criteria for grievance classification or plan-initiated disenrollment to management for further follow-up and resolution.


• Provides assistance with bills received from providers by documenting and referring to Claims department provider bills received by Medicare members for services authorized and/or covered by Community Health Group.


• Participate in the department’s on-call schedule, which includes after business hours, weekend and holiday coverage.


• Complete "Welcome Calls" within the first two weeks of every month (will require about 10 hours of overtime per month).


• Works closely with community based ethnic service and advocacy programs by identifying the Medicare member’s/family’s non-medical and social needs and referring these to the appropriate organizations for assistance.


• Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.


• This position requires occasional travel within the San Diego County area.

Qualifications

Education: Bachelor's Degree in a Health or Human Services Field required (Health Education, Psychology, Sociology, Health Sciences, Public Health, Social Work, Nursing)

Within one year of eligibility, must take the Certified Case Manager test. Must pass the test within 12 months of the date of eligibility to retain employment.

Experience / Skills

• Two years of experience in Customer Service (preferably in the health care industry).


• Strong customer service background.


• Familiarity with case documentation practices.


• Experience with and sensitivity to cultural background and linguistic needs of membership.


• Familiarity and respect for special social needs of Medicare populations.


• Knowledge of Medicare program eligibility requirements and familiarity with services available through community based ethnic service and advocacy organizations throughout San Diego preferred.


• Bilingual English/Spanish, English/Vietnamese, or English/Arabic


• Excellent communication and interpersonal skills.


• Ability to exercise mature and independent judgment.


• Ability to secure reliable transportation and possess a valid driver’s license as well as proof of vehicle insurance

Physical Requirements

• Prolonged periods of sitting.


• Extensive use of telephone.


• Will be required to work evenings and/or weekends.

The above statements describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.

All qualified applicants will receive consideration for employment based on merit, without regard to race, color, religion, sex, national origin, disability, protected Veteran Status, or any other characteristic protected by applicable federal, state, or local law.