Member Care Representative

Unilogic Healthcare Management, LLC.; Los Angeles (CA); On-site; USD 40,000 - 52,000; Full time

Job summary

Unilogic Healthcare Management, LLC is seeking a Member Care Representative to work closely with enrollees and ensure completion of quality programs. You will perform 30/60/90-day evaluations, conduct outreach campaigns, and coordinate with providers to guarantee required care, while meeting daily outbound call goals and documenting progress in Cozeva and related systems.

Candidates should have strong customer service experience, knowledge of Medi-Cal/Medicare plans is a plus, and be proficient

Qualifications

• High school diploma or GED; related healthcare or managed care experience preferred.
• Two years of customer service experience required.
• Knowledge of Medi-Cal, Commercial or Medicare plans is a plus.
• Healthcare outreach experience is desirable.

Responsibilities

• Conduct special program outreach campaigns to assigned members and ensure program completion.
• Perform 30/60/90-day evaluations to monitor duties and probation status.
• Maintain 85% compliance rate or 4-star equivalent on Star Measures.
• Assist members in obtaining required care and coordinate with providers.
• Coordinate with field team to complete home visits and meet campaign goals.
• Meet daily outbound call targets; address inbound calls promptly.
• Utilize Office 365, Five9, Cozeva, Outlook and Excel as required.
• Document progress in Cozeva or related systems and report weekly.
• Collaborate with QI and Member Care Advocates on campaigns.
• Escalate physician and member concerns professionally and resolve issues.
• Perform data sweeps to collect medical records and upload results.

Skills

Customer service

Outreach campaigns

Data entry

Communication skills

Time management

Education

High school diploma or GED

Medical Assistance Certificate (preferred)

Phlebotomy License (preferred)

Tools

Cozeva

Five9

Office Suite

Excel

Job description

The Member Care Representative works closely with assigned enrollees to ensure that the quality programs they qualify for are completed. You will have 30/60/90-day evaluations to determine if the essential duties and responsibilities are being met and if you have passed the 90-day probationary period.

Essential Duties and responsibilities include, but are not limited to:

Conduct special program outreach campaigns to assigned members. Programs related categories are as follow, but no limited to: Categories vary for each Representative.

Initial Health Assessment

Annual Health Assessments

STAR / HEDIS Measures

Maintain a minimum 85 % compliance rate or 4-star equivalent on assigned Star Measures. Potential star measures are as follows, but not limited to: Measures could vary for each Representative.

Breast Cancer Screening

COA – Medication Review and List

COA- Pain Screening

HBA1C

Diabetic Eye Screening

MRPD

KED

CBP

OMW

Make all attempts to assist members in obtaining required care and coordinate with assigned team members,provider offices to guarantee the member receives the care needed.

Coordinate with field team to ensure member home visits are completed to comply with campaign goals.

Ensure daily outreach call goals are met per campaign.

Use systems such as Office @ hand, Five9, Cozeva, Outlook and Excel as advised.

Collaborate and Coordinate with QI department team members to complete all outreaches in appropriate time frame.

Foster good corporate relations by practicing good customer service principles (i.e., positive attitude, helpful, etc.).

Identify challenges, errors, problems within the processes and ensure follow-up actions are taken to resolve the matter so that your productivity is not impacted.

Properly document the progress of each assigned member in Cozeva or other related systems.

Report progress of assigned programs within appropriate time frame.

Collaborate with QI Department Specialist and Member Care Advocates for campaigns associated to assigned providers.

Escalate physician office and member concerns in a professional fashion and ensure that they are addressed.

Perform Data Sweeps to collect medical records from specialist and PCP office.

Retrieve results and upload to Cozeva and/or Shared drive.

Perform other duties and responsibilities assigned by department director.

Member Care Representative are required to maintain a minimum of 50-60 daily outbound call minimum and

ensure that all inbound calls are addressed.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience: High School or general education degree (GED); or on to three months related experience and/or training; or equivalent combination of education and experience.

Medical Assistance Certificate: Not required but preferred.

Phlebotomy License: Preferred but not required.

Other Qualifications:

Two years customer service experience

Health Plan Outreach Experience

Direct member communication, preferably in the Medi-Cal, Commercial, or Medicare Managed Care industry preferred.

Knowledge of Medi-Cal, Commercial, and Medicare Managed Care Plans preferred.

Skills and Abilities

Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization.

Mathematical Skills: Ability to add and subtract two-digit numbers and to multiply and divide with 10s and 100s. Ability to perform these operations using units of American money and weight measurement, volume and distance.

Reasoning Skills: Ability to apply common sense understanding to carry out detailed but variables in standardized situations.