Member Services Representative - Medi-Cal (Bilingual)

Inland Empire Health Plan•Rancho Cucamonga, CA

12d•Hybrid

About The Position

The Member Services Representative advocates for Medi-Cal members by helping them understand their health plan benefits and navigate the healthcare system. The role provides assistance with benefit inquiries, claims, wellness programs, provider and facility assignments, eligibility, and access to services. Representatives work with other departments to resolve member and provider questions, coordinate translation for callers who do not speak English or Spanish, and meet monthly performance goals. This is a bilingual position; team members identified as bilingual must pass a language proficiency assessment. The position requires accurate call documentation, timely grievance intake, protection of members’ personal health information, and compliance with applicable regulatory requirements and IEHP policies. Representatives also participate in ongoing training and process-improvement activities, review call-monitoring feedback, help track and escalate trends, and support members in using self-service options. The work model is hybrid, with three days onsite and two days at home. The department operates 24/7, with availability for day, swing, and overnight shifts and weekend and holiday coverage as needed. Scheduling is flexible based on business needs.

Requirements

High school diploma or GED.
At least one year of customer service experience analyzing and solving customer problems.
Bilingual role requirement: identified bilingual team members must take and pass a language proficiency assessment.
Proficiency in Microsoft Office Suite and Windows-based programs.
Typing speed of at least 35 words per minute.
Good grammar and spelling skills.
Excellent oral communication skills.
Availability for day, swing, and overnight shifts in a 24/7 operation, with weekend and holiday coverage as needed.

Nice To Haves

HMO or managed care experience.
At least one year of call center experience in a customer service setting.
Experience with Medi-Cal programs and benefit requirements.

Responsibilities

Educate members about Medi-Cal benefits, coverage, coordination of benefits, and eligibility rules.
Meet Member Services Call Center standards and policy requirements, including completing training, participating in ongoing training, using the telephone system and other equipment appropriately, following call scripts, and complying with attendance, punctuality, and dress-code policies.
Provide respectful, patient, prompt service and strive to resolve caller needs at first contact while meeting call-handling standards.
Assist with primary care and facility assignments, selections, and changes; health care options; health education; and provider eligibility-status inquiries.
Educate members about available materials, programs, ID cards, and how to access services.
Present cases to Member Services management and work with other departments to resolve member and provider inquiries, including transportation, interpreter requests, referrals, redirections, behavioral health, and pharmacy issues.
Document calls accurately while speaking with callers; complete member satisfaction surveys and assessments as needed; and meet the stated call-documentation requirement.
Intake member grievances properly and on time.
Coordinate telephonic translation when members do not speak English or Spanish.
Use problem-solving, time-management, initiative, and focus skills while working with minimal supervision and guidance.
Adapt to changing systems and business conditions and use technology effectively.
Meet monthly key performance indicator goals.
Protect the privacy and security of protected health information and comply with HIPAA-related policies and procedures and applicable regulatory requirements.
Authenticate callers and preserve confidentiality, including handling guardianship documentation, guardianship alerts, authentication passwords, and confidentiality alerts as needed.
Participate in LEAN process-improvement projects and RIE events or huddles, and submit ideas for efficiency gains.
Help members navigate self-service options.
Track department trends and escalate relevant information to management.
Review call-monitoring recordings and develop self-action plans to improve quality-assurance scores.
Maintain knowledge of other departments and their roles in Member Services processes to route and handle calls appropriately.
Comply with the IEHP Telecommuting Agreement and applicable requirements.