Member Services Representative - Medi-Cal (Bilingual)

Inland Empire Health Plan•Rancho Cucamonga, CA

13d•Hybrid

About The Position

The Member Services Representative advocates for Medi-Cal members by helping them understand and maximize their benefits and navigate the healthcare system. The role provides service for benefit and eligibility inquiries, claims, wellness programs, and access to services, while coordinating with other departments to resolve member and provider questions. Responsibilities also include arranging telephonic interpretation for callers who speak neither English nor Spanish, documenting calls, resolving issues, and meeting monthly performance indicators. This is a bilingual position; identified bilingual team members must pass a language proficiency assessment. The position supports IEHP’s Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation, and requires protecting members’ protected health information and complying with HIPAA and other applicable regulatory requirements. The work model is hybrid, with three days onsite and two days at home. The operation runs 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

At least one year of customer service experience analyzing and solving customer problems.
High school diploma or GED.
Bilingual language proficiency assessment and passing score for team members identified as bilingual.
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.

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 and coverage, coordination of benefits, and eligibility rules.
Meet Member Services Call Center standards and policies, including completing training, participating in ongoing training, using telephone systems and other equipment appropriately, following call scripts, and complying with attendance, punctuality, and dress code policies.
Provide high-quality service, aiming to resolve callers’ needs on first contact while showing patience and respect and meeting call-handling standards.
Assist with primary care and facility assignments, selections, and changes; health care options liaison needs; health education inquiries; and provider requests for member eligibility status.
Educate members about available programs and services, request materials, order identification cards, and help members access services.
Present cases to Member Services management when needed and coordinate with other departments to resolve member or provider inquiries, including transportation, interpreter, referral, redirection, behavioral health, and pharmacy matters.
Document calls accurately while speaking with callers; complete member satisfaction surveys and assessments as needed; and maintain the required call documentation.
Intake member grievances properly and promptly.
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.
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 IEHP policies, HIPAA, and applicable regulatory requirements.
Authenticate callers and preserve member confidentiality, including handling guardianship documents, alerts, passwords, and confidentiality alerts as needed.
Participate in LEAN process-improvement projects and RIE events or huddles, and submit ideas for efficiency improvements.
Help members navigate self-service options.
Track departmental 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.