Navigator II (ON SITE- Lynwood Location)

L.A. Care Health Plan•Los Angeles, CA

7d•$60,778 - $91,166•Onsite

About The Position

The Navigator II is responsible for resolving member inquiries and coordinating care for complex cases. This includes managing benefit coordination, continuity of care, access to care, quality of care issues, member eligibility, assignment, and disenrollment issues across various product lines (Medi-Cal, L.A. Care Covered, Cal MediConnect). The primary focus is on ensuring member satisfaction. The position also handles disenrollments in coordination with the UM department and Plan Partners, adhering to guidelines from DHS, CMS, NCQA, and L.A. Care. The Navigator ensures the proper and expeditious handling of member issues presented by various stakeholders, including members, the Ombudsman, state contractors, member advocates, ECAC, and L.A. Care Board Members. They manage and coordinate the identification, documentation, investigation, and resolution of complex cases in a timely and culturally-appropriate manner. This involves coordinating multi-departmental processes (Customer Engagement & Experience, PNO, Claims, UM, Pharmacy, Medicare Enrollment/Disenrollment, Product Sales, and QM) to identify gaps in coverage and resolve cases to the members' satisfaction, referring cases to plan partners when applicable. The Navigator will be stationed at designated Community Resource Center/Walk-In Centers and may provide support at other locations as needed.

Requirements

At least 2 years of experience resolving health care eligibility, access, grievance and appeals issues, preferably in health services, legal services and /or public services or public benefits programs with claims and Medicare experience.
Strong customer service skills.
Excellent oral and written communication skills.
Strong analytical and conflict resolutions skills as well as persuasion skills.
Proficient in MS Office applications, Word, Excel, Power Point, and Access.
Travel to offsite locations for work.

Nice To Haves

Health Plan background a plus along with strong advocacy background.
Medical terminology.
Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.

Responsibilities

Coordinate multi-departmental processes to resolve members 'issues and complex cases to the members' satisfaction. This process may include referrals to plan partners to ensure compliance with regulatory and L. A. Care guidelines. Ensure to follow departmental guidelines/matrixes for all processes. Urgent complex cases will be handled within 24hrs. All others within 48hrs.
Work as a navigator to our Medicare Line Of Business (LOB): A. Ensure to meet deadline for completion of Welcome Calls; B. Ensure to follow through on all cases forwarded to other areas for assistance; C. Document all transportation services provided to each member. Ensure to confirm appointment and authorization; D. Coordinate/assist with all other departments regarding Medicare Services; E. Thorough Reinstatement of enrollment of members whose disenrollment are questionable; F. Identify and complete Organization and Coverage Determination for timeliness and resolution; G. Ensure proper Guidelines are followed for Medicare disenrollment request; H. Ensure to complete all BAE and/or LIS request.
Identify potential quality of care issues and referral to QM Department, through calls received from our Contact Center and other internal customers.
Handle disenrollment's requests from members, providers and plan partners: 1) Long Term Care (Exhaustion of Benefits); 2) Move out of County; 3) Major Organ Transfers; 4) Incarceration; 5) Foster Care.
Work with Compliance department regarding suspected fraudulent activities received through the L.A. Care hot line and the Contact Center personnel.
Communicate with collection agencies, billing business offices regarding delinquent and problematic member accounts which includes claims issues from L.A Care Medi-Cal Direct Program (MCLA), Healthy Families (HF), Healthy Kids (HK), and Special Needs Populations (SNP) members.
Work with Cultural & Linguistic (C&L) to provide translations for members' correspondence into the appropriate languages. As requested review documents submitted by C&L to ensure proper translation and culturally sensitive materials for distribution to our members (brochures pamphlets and educational materials).
Meet general L.A. Care requirements for attendance and punctuality and follow department guidelines.
Perform other duties as assigned.