Note The job is a remote job and is open to candidates in USA. Astrana Health is looking for a Customer Service Representative to join their fast and growing Dynamic team. This position requires speaking fluent Spanish and involves answering calls, collecting information, and assisting members and providers with various inquiries.

Responsibilities

• Answer all daily telephone calls from members, providers, health plans, insurance brokers, collection agents and hospitals
• Collect Elicit information from members/providers including the problem or concerns and provide general status information
• Verify authorization, claims, eligibility, and status only
• All calls carefully documented into Company’s customer service module & NMM Queue system
• Member/Provider Service/Representative assists Supervisor and Manager with other duties as assigned
• Member outreach communications via mail or telephone
• Assist Member appointment with providers
• Resolve walk-in member concerns
• Able to provide quality service to the customers
• Able to communicate effectively with customers in a professional and respectful manner
• Maintain strictest confidentiality at all times
• Specialist termination notifications sent to members
• Urgent Medicare Authorization Approval – Notification to Medicare members
• Transportation arrangement for Medicare & Medi-Cal members
• Outreach Project Assignments
• INBOUND CALLS Member/Provider/Health Plan/Vendor/Hospital/Broker All calls carefully documented into Company’s customer service module
• Annual Wellness Visit (AWV) – Gift card pick up and schedules
• Appointment of Representative (AOR) for Medicare Members
• Attorney / Third Party Vendor calls
• Authorization status/Modification/Redirection/CPT Code changes/Quantity adds/Explain Denied Auth/Peer to Peer calls/Extend expired auth/Pre-certified auth status/Retro/2ndor 3rd opinion/Conduct 3 way conference call to Health Plan with member
• Conference call with Providers – Appointments, DME,COVID – 19 related questions (Tests & Vaccines)
• Direct Member Reimbursement (DMR)
• Eligibility – Demographic changes Address/Phone/Fax Changes/Name change
• Escalated calls from providers/members
• Health Diary Passport
• Health Source MSO – Assist & arrange inquiries on Eligibility/Change PCP/Benefit with AHM
• CHIPPA Consent – Obtain Member Consent verification
• Inquiries on provider network/provider rosters
• Lab locations
• Member & Provider Complaints/Grievances
• Member bills
• Miscellaneous calls
• Pharmacy – Drug/medication pick up and coverage
• Provide authorization status for Hospital /CM Dept
• Self-Referral Request for Medicare
• Return Mail
• Track Mail Packages/ Certified mail status
• Translations – Spanish / Chinese
• Urgent Care / locations/ operations hours
• OUTBOUND CALLS Member/Provider/Health Plan/Vendor/Hospital/Broker Assist Case Management on CCS – age in 21 years for change of PCP from Pediatrics to FP/IM
• Assist Marketing on email inquiries
• Assist PR/ Elig – Members assigned to wrong PCP/with no PCP status
• Assisted UM / Medical Directors on urgent member appointment from escalated cases
• Authorization status response call back
• Benefits – return call once information is obtained / verified
• Complaints/Grievances – return calls once resolution is obtained
• DME – Translation support in Spanish and Chinese to confirm item / appointment set up for DME department
• Eligibility – return call to providers/labs when member is added to system while waiting at the office
• Member bills – return calls once resolution is obtained
• Member Survey – Annually every 4thquarter
• Outreach project from internals – QCIT
• Resolve walk in members concerns
• Specialist Termination notification sent to members
• Transportation arrangement for Medicare / Medi-Cal members
• Voice mail – return calls back to callers
• CONCIERGE SERVICES – ESSENTIALS DUTIES AND REQUIREMENTS Assist to contact new members/IPA member transfer on new PCP assignment as needed
• Work group discussions on work status/progress on new member/IPA transfer
• Update call log and provide daily/weekly status as needed
• Facilitate members with complex pre-existing conditions, medications, PCP/SPC network reviews
• Conference call with PCP selection / change
• Help member to identify member bill status, connect provider with on billing and claim submission
• Responsible for experience of the membership associated with new member/IPA transfer
• Responsible for to interact with Health Plan’s Customer Service Team to serve new member/IPA transfer
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