Job ID# 10021661 – Posted 12/07/22 – Los Angeles, CA

The Customer Center Member Navigator is responsible for resolving member inquiries. Coordination of care for complex cases which may involve benefit coordination, continuity of care, access to care, quality of care issues, member eligibility, assignment, disenrollment’s issues and interpreting requests for all product lines (Medi-Cal, CMC). It will be expected that the main focus is to provide member satisfaction. In addition, this position is responsible for handling disenrollment’s in coordination with Plan Partners. The Navigator handles and coordinates the identification, documentation, investigation and resolution of complex cases, in a timely and culturally-appropriate manner. Coordinates multi-departmental processes to ensure identification of member’s claims of gaps in coverage and resolution of cases for members’ satisfaction and of referral cases to plan partners when applicable.
The Navigator will be stationed and available to assist members at any of designated locations. Will provide Navigator support at other locations as needed.

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 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 Medicare LOB:
1. Ensure to meet deadline for completion of Welcome Calls;
2. Ensure to follow through on all cases forwarded to other areas for assistance;
3. Document all transportation services provided to each member. Ensure to confirm appointment and authorization;
4. Coordinate/assist with all other departments regarding Medicare Services;
5. Thorough Reinstatement of enrollment of members whose disenrollment are questionable;
6. Identify and complete Organization and Coverage Determination for timeliness and resolution;
7. Ensure proper Guidelines are followed for Medicare disenrollment request;
8. 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 Call Center and other internal customers.
Handle disenrollment’s requests from and 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.

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.
Medical terminology a plus.
Bilingual in one of following languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.

1-2 years 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.
Health Plan background a plus along with strong advocacy background.

Associate’s degree or higher.

Please send your resume and any additional information to our recruitment team at recruitment@nexlogica.com