Navigator II (ON SITE- West Los Angeles Location)

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan, serving more than 2 million members. Our mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

About the role

The Navigator II is responsible for resolving member inquiries. Coordination of care for complex cases may involve benefit coordination, continuity of care, access to care, quality of care issues, member eligibility, assignment, disenrollment issues, and interpreting requests for all product lines (Medi-Cal, L.A. Care Covered, Cal MediConnect (CMC)). The main focus is to provide member satisfaction.

This position handles disenrollments in coordination with the Utilization Management department and plan partners such as the Department of Health Services (DHS), Centers for Medicare and Medicaid Services (CMS), and National Committee for Quality Assurance (NCQA), following L.A. Care guidelines. The Navigator ensures proper handling of member issues presented by members, Ombudsman, state contractors, member advocates, Executive Community Advisory Committee (ECAC), L.A. Care Board Members, or providers, resolving them expeditiously.

The Navigator coordinates the identification, documentation, investigation, and resolution of complex cases in a timely and culturally appropriate manner. They work across multiple departments (Customer Engagement & Experience, Product Network Operations (PNO), Claims, Utilization Management (UM), Pharmacy, Medicare Enrollment/Disenrollment, Product Sales, and Quality Management (QM)) to identify and resolve member claims of gaps in coverage. The Navigator may be stationed at any designated Community Resource Center/Walk-In Center and will provide support at other locations as needed.

Responsibilities

• Coordinate multi-departmental processes to resolve members' issues and complex cases to the members' satisfaction, including referrals to plan partners to ensure compliance with regulatory and L.A. Care guidelines. Follow departmental guidelines/matrices for all processes. Urgent complex cases will be handled within 24 hours; all others within 48 hours. (30%)
• Act as a navigator for the Medicare Line of Business (LOB):
  • Ensure deadlines are met for completion of Welcome Calls.
  • Follow through on all cases forwarded to other areas for assistance.
  • Document all transportation services provided to each member, confirming appointments and authorizations.
  • Coordinate/assist with all other departments regarding Medicare Services.
  • Thoroughly reinstate enrollment of members whose disenrollment is questionable.
  • Identify and complete Organization and Coverage Determinations for timeliness and resolution.
  • Ensure proper guidelines are followed for Medicare disenrollment requests.
  • Complete all BAE and/or LIS requests.
  (25%)
• Identify potential quality of care issues and refer them to the Quality Management (QM) Department through calls received from the Contact Center and other internal customers. (10%)
• Handle disenrollment requests from members, providers, and plan partners for the following reasons:
  • Long Term Care (Exhaustion of Benefits)
  • Move out of County
  • Major Organ Transfers
  • Incarceration
  • Foster Care
  (5%)
• Work with the Compliance department regarding suspected fraudulent activities received through the L.A. Care hotline and Contact Center personnel. (5%)
• Communicate with collection agencies and billing business offices regarding delinquent and problematic member accounts, including claims issues from L.A. Care Medi-Cal Direct Program (MCLA), Healthy Families (HF), Healthy Kids (HK), and Special Needs Populations (SNP) members. (5%)
• Work with Cultural & Linguistic (C&L) to provide translations for members' correspondence into appropriate languages. Review documents submitted by C&L to ensure proper translation and culturally sensitive materials for distribution to members (e.g., brochures, pamphlets, and educational materials). (5%)
• Meet general L.A. Care requirements for attendance and punctuality and follow department guidelines. (5%)
• Perform other duties as assigned. (10%)

Requirements

• Associate's Degree. In lieu of a degree, equivalent education and/or experience may be considered.
• 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.

Qualifications

• Strong customer service skills.
• Excellent oral and written communication skills.
• Strong analytical, conflict resolution, and persuasion skills.
• Proficient in MS Office applications (Word, Excel, PowerPoint, and Access).
• Preferred: Knowledge of 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.

Benefits

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental, and Vision
• Wellness Program
• Volunteer Time Off (VTO)

Pay

Salary Range: $60,778.00 (Min.) - $75,950.00 (Mid.) - $91,166.00 (Max.)