Customer Service Navigator

W2 contract role located in South San Francisco, CA (onsite).

About the role

Under direct supervision, respond to member and provider inquiries by telephone and other communication channels, providing members with comprehensive support regarding health plan benefits and services. Acts as the primary point of contact for members, delivering prompt, accurate, and courteous assistance via telephone and other communication channels, whether for general inquiries, concerns, or information requests about programs, services, eligibility, or benefits.

Responsibilities

• Handle inbound and outbound calls and other communications in a high-volume environment, providing excellent customer service and professionalism, in accordance with established policies and procedures, and meeting established performance and quality metrics.
• Adhere to established guidelines, call scripts, and resources to address member and provider inquiries; maintain confidentiality of member information and comply with HIPAA and other relevant regulations.
• For non-routine inquiries, leverage available resources and expertise to resolve issues that fall outside standard protocols.
• Resolve concerns accurately, promptly, professionally, and with cultural competence; ensure explanations are appropriate to the member's level of understanding and knowledge.
• Intake, handle, and coordinate member grievances, appeals, and billing issues, escalating to the Grievance and Appeals department when necessary.
• Educate members and providers about eligibility, benefits, and the provider network; assist members in selecting or changing their primary care physician and provide accurate information about available providers and effective dates for PCP assignments.
• Use listening skills and judgment to appropriately categorize and accurately document all interactions and follow-up actions regarding member and provider communications in accordance with established guidelines.
• Refer members to appropriate community partner agencies based on their specific needs, including Behavioral Health and Recovery Services, Aging and Adult Services, Legal Aid, Human Services Agency, and HICAP when applicable.
• Use strong professional judgment to determine when to escalate member or provider inquiries to other departments; share important information and collaborate with teams to resolve issues, including referring members to health services for care coordination.
• Proactively seek opportunities to improve processes and enhance the overall member experience.
• Attend and actively participate in regular departmental meetings, training sessions, and coaching sessions.
• Cross-train on a variety of tasks as requested to ensure continuity of operations.
• Conduct member outreach such as welcome calls and targeted outreach calls as assigned.
• Participate in and represent the company professionally at health fairs, community partnerships, meetings, committees, and coalitions as assigned.

Requirements

• High school diploma or GED.
• One (1) or more years of experience in a Customer Service or Call Center role, preferably in a healthcare or public-sector setting.
• Previous experience with managed care plans, Medi-Cal, and Medicare programs, and working with underserved populations preferred.
• Knowledge of Microsoft Office products, including Word, Excel, PowerPoint, and Outlook.
• Knowledge of health insurance and medical terminology.
• Bilingual skills in Spanish, Mandarin, Cantonese, or Tagalog are preferred but not required.
• Ability to communicate effectively both verbally and in writing with diverse audiences.
• Ability to maintain health information confidentiality and follow HIPAA privacy and security best practices.

Skills

• Customer Service
• Call Center Operations
• Member Services
• Provider Services
• Health Insurance
• Managed Care
• Medi-Cal
• Medicare
• Health Plan Benefits
• Eligibility Verification
• Provider Networks
• Primary Care Physician Assignments
• Inbound Calls
• Outbound Calls
• Member Outreach
• Grievances and Appeals
• Billing Issue Resolution
• Complaint Resolution
• Issue Escalation
• Care Coordination
• Community Resource Referrals
• Interaction Documentation
• HIPAA Compliance
• Patient Confidentiality
• Medical Terminology
• Cultural Competence
• Active Listening
• Verbal Communication
• Written Communication
• Cross-Functional Collaboration
• Process Improvement
• Quality Metrics
• Microsoft Word
• Microsoft Excel
• Microsoft PowerPoint
• Microsoft Outlook
• Bilingual Communication

Pay

$26.56 - $33.59 per hour.