Community Based Program Coordinator

Santa Clara County Health Authority•San Jose, CA

9d•Onsite

About The Position

The Community Based Programs (CBP) Coordinator leads and participates in processes and projects to support and improve the operations of the Community Based Programs (CBP) team in alignment with organizational objectives, and in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements. In this role, the Coordinator supports the daily operations of CBP benefits, programs and strategies including serving as primary initial contact for specific referrals and authorization processes.

Requirements

High school diploma or GED.
Minimum two years of experience in customer service, program operations, health services, or in a managed care or community based setting handling escalated or complex issues.
Maintenance of a valid California driver’s license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or event.

Nice To Haves

Associate’s degree or equivalent experience, training or coursework.
Knowledge of health plan benefits, process and operations.
Experience and comfort working with data entry and system software applications.
Prior experience with public or nonprofit programs, Medi-Cal and/or Medicare programs and working with the underserved populations.
Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills.
Experience with SQL development language and/or Tableau.

Responsibilities

Oversee the processes for referrals and authorizations, including processing the denial and disenrollment for Medi-Cal benefits under the CBP Team in accordance with state and federal regulatory requirements and SCFHP policies and procedures as set forth for each benefit
Perform complete, accurate and consistent authorization processes including review of benefit eligibility and referrals, request and review of medical records and other documentation, as applicable, escalation to clinical staff or management for further determination, and process approval and denial letters or Notice of Action.
Act as the primary initial contact for CBP referrals and communicate with internal departments for additional follow up as necessary and appropriate.
Perform routine duties including accurate and consistent data entry into system software applications, managing and following up on call queues, and working to resolve member and provider inquiries in a timely manner.
Serve as liaison with Grievance and Appeals (G&A) Department for support with CBP related reviews and resolution of member and/or provider issues submitted by G&A
Ensure grievance and appeals cases are accurate and include the necessary elements for processing and resolving, giving special attention to those identified as “Expedite”. Create clear and concise documentation in applicable system(s).
Support needs of the CBP team including scheduling, coordinating and documenting meetings, maintaining records, generating mailing lists, setting up documents, onboarding staff and implementing other projects in support of CBP strategies.
Support team staff on reviewing and providing input on member and provider facing materials, including program guides, training slides, and member information flyers
Support management in the process of approving policies, as well as the upload and updating of policy and procedures to PolicyTech platform.
Follow established Health Services policies and procedures and use available resources to respond to member and/or provider inquiries and resolve any concerns in an accurate, timely, respectful, professional and culturally competent manner
Build and maintain expertise and understanding of managed care, SCFHP policies and procedures, department functions and processes and relevant regulatory requirements.
Collaborate with team members on improvement efforts across-departments regarding quality improvement projects, optimization of utilization management, and member satisfaction
Assist in gathering and processing data for internal required reports and analysis.
Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions.
Process written and verbal notifications of authorization determinations to members and/or providers within regulatory processing timeframes.
Perform other duties as required or assigned.