Lead Health Navigator - Internal Applicants Only

Moda Health•Milwaukie, OR

1d•Remote

About The Position

Provides phone, email, SMS, and chat-based customer service to members of certain Performance Guarantee (PG) and Moda 360 groups by analyzing caller’s needs and providing timely and accurate responses. Answers inquiries from policyholders, members, agents, providers, hospitals, pharmacists, dentists, and others regarding a wide variety of issues and questions related to a member’s benefits and health program options. Supports the Health Navigator team and supervisor. This position requires staff to be flexible with their work schedule to meet the client’s needs. This is a Full-Time Work From Home role.

Requirements

High school diploma or equivalent.
Minimum 1-2 years of experience at Moda (or equivalent experience outside of Moda) providing customer service in Medical, Dental and/or Pharmacy Customer Service.
CSR II or department equivalent preferred.
Health Navigator experience strongly preferred.
Ability to meet and exceed all department standards and coach staff members to meet standards.
Strong verbal, writing and interpersonal skills.
Experience projecting empathy/passion for working with all customers and co-workers.
Strong analytical, problem solving, and decision-making skills with demonstrated ability to independently handle and resolve complaints, correct errors and resolve issues in accordance with Moda policies.
10-key proficiency of 105 kpm net on a computer numeric keypad.
Type a minimum of 25 wpm net on computer keyboard.
Ability to become a unit expert on online resources and applications including Facets, Benefit Tracker, Content Manager, MedAccess/Navitus, CoverMyMeds, Moda 360 Health Navigator Console, MS Teams, OneNote and others.
Ability to work well under pressure while providing excellent customer service and helping the unit meet all service levels.
Thorough knowledge of all groups assigned.
Thorough knowledge and understanding of requirements and Moda administrative policies affecting medical, dental and pharmacy claims.
Ability to maintain confidentiality and project a professional business presence and appearance.
Ability to back up supervisor, answer questions from CSRs, assist in training and complete reports.
Demonstrated ability to consistently organize work and time to meet deadlines and complete work in a timely manner.
Ability to maintain excellent attendance and punctuality and request time off with advance notice.
Demonstrated ability to comply with company rules and policies and project a positive and accepting attitude.
Completed Effortless Experience course and certification, or ability to complete soon after hire.

Nice To Haves

CSR II or department equivalent preferred.
Health Navigator experience strongly preferred.

Responsibilities

Provide back up and support to supervisor of unit, including monitoring absence and overtime, monitoring phone line service levels, evaluating performance, training (individual and classroom), orientation, and one-on-ones with Health Navigators.
Assist in the hiring process and the employee disciplinary process.
Answer medical, dental, and pharmacy claim and benefit questions from internal and external customers and team members on Moda 360 dedicated groups.
Act as a primary resource for all departments on questions and issues relating to these groups.
Maintain knowledge in standard CS groups in order to assist those teams.
Handle escalated calls and issues from various sources, including incoming calls from customers and emails from internal departments.
Assign work to staff as needed, including projects, outreach requests and task lists.
Gather and communicate monthly performance metrics and audit results to each staff member timely and completely.
Review any rebutted audit results, listening to the call as needed.
Explain the rationale behind the audit or send to the Auditing team for review based on the outcome.
Monitor Facets To-Do list, email inboxes and MS Teams chat regularly and prioritize questions and requests in order to meet the needs of staff members, their callers and other departments.
Repeatedly analyze situations and communicate effectively in a fast-paced environment that includes working with frustrated or angry callers.
Use multiple resources simultaneously to research member issues or questions from staff, including Facets, Benefit Tracker, Content Manager, eviCore portal, Navitus, CoverMyMeds and other internal and external websites.
Monitor phone and chat lines to assist in handling these contacts during periods of high volume.
Provide accurate information timely and in a professional manner both verbally and in writing.
Apply mathematical skills to determine correct benefit information and accurate customer service statistics.
Exercise judgment, initiative, and discretion with confidential and sensitive subject matter.
Provide thorough resolution when at all possible for members by using critical thinking skills, extending yourself and reducing effort on the part of the caller.
This could include reaching out to internal and external sources (including service providers) to assist in resolving the issue for the member.
Assist team members in determining the best course of action and next steps for resolving caller issues, focusing on providing resources and support to allow them to better resolve issues independently in the future.
Demonstrate empathy and respect for all team members and support positive communication within the team.
Review, update and become familiar with new and revised benefit information and communicate to staff.
Build and maintain proficiency in claim processing procedures to determine whether a claim was processed or adjusted correctly.
Communicate reasoning to callers and Health Navigators in language appropriate to experience level.
Request claim adjustments required due to processing or configuration errors or new information and determine which incorrect processing is the result of a configuration error versus a processing error.
When a configuration error is encountered, communicate with the appropriate department to have it corrected.
Identify confusing or incomplete information in all internal and external resources, plan documents and member communications and make suggestions for improvements.
Complete provider searches that may include calling several providers to locate providers who are in-network, available and meet the member’s care needs.
Work with internal departments to help resolve member gaps in care when possible, including work with the Healthcare Services or Pharmacy teams on exceptions and authorizations.
Advocate on behalf of members when they encounter issues with obtaining covered care or medications from providers or pharmacies.
Place overrides to allow pharmacies to dispense medication at the point of service when appropriate based on plan details and internal policies.
Address and explain complaints, appeals, and grievances.
Provide customer service to walk-in members.
Contact physicians, dentists, hospitals, pharmacies and other providers when necessary to answer questions and obtain or provide information.
Send emails or text messages to members to follow up on call details or provide forms, website links or other plan documents and review Health Navigator emails for accuracy.
Provide timely follow up and return calls when these are required.
Answer contacts as needed to maintain PG service level agreement.
Participate in User Acceptance Testing and workgroups as assigned.
Attend meetings with internal and external participants at all levels.
Create job aids and resources for staff, and request updates to Policy and Procedure manuals.
Monitor staff To-Do lists to ensure that they are completing tasks within department TAT, send reminders and offer support as needed to keep tasks current.
Perform other related duties and projects as assigned by supervisor or manager.