Customer Service Navigator

W2 Contract

Salary Range: $52,000 - $62,400 per year

Location: South San Francisco, CA - Onsite Role

Job Summary:

As a Customer Service Navigator, you will respond to health plan member and provider inquiries by telephone and other communication channels, providing members with comprehensive support regarding health plan benefits and services. You will act as the primary point of contact for members, delivering prompt, accurate, and courteous assistance, whether for general inquiries, concerns, or information requests about health care programs, services, eligibility, or benefits.

Duties and Responsibilities:

• Handle inbound and outbound calls and other communications in a high-volume environment, providing excellent customer service and professionalism following established policies and procedures and meeting performance and quality metrics.
• Adhere to established guidelines, call scripts, and resources to address member and provider inquiries, including maintaining the confidentiality of member information and complying with HIPAA and other relevant regulations. For non-routine inquiries, leverage available resources and expertise to resolve issues outside standard protocols.
• Resolve concerns accurately, promptly, professionally, and with cultural competence; ensure that 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 our 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 and activities per established guidelines.
• When applicable, 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.
• 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 and guiding providers to specialists for help with complex claims or questions.
• 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 as applicable.
• Cross-train on various tasks as requested to ensure the continuity of operations within the Member Services department and other departments.
• Conduct member outreach such as welcome calls and targeted member outreach calls as assigned.
• Participate in and represent the company professionally at health fairs, community partnerships, meetings, committees, and coalitions.
• Develop and proactively maintain up-to-date knowledge of relevant quality, regulatory, and organizational guidelines.
• Perform problem research, use analytical skills, and effectively influence positive outcomes.
• Maintain health information confidentiality and follow information privacy and security best practices.

Requirements and Qualifications:

• High school diploma or GED
• 1+ year(s) of experience in Customer Service or Call Center role, preferably in a health care or public-sector setting
• Previous experience with managed care plans, Medi-Cal and Medicare programs, and working with underserved populations.
• Skilled with Microsoft Office products, including Word, Excel, PowerPoint, and Outlook.
• Knowledge of Health insurance and medical terminology.
• Familiar with quality metrics relevant to a call center and best practices for achieving them.
• Strong computer and typing proficiency
• Bilingual skills in Spanish, Mandarin, Cantonese, or Tagalog are preferred but not required.

Bayside Solutions, Inc. is not able to sponsor any candidates at this time. Additionally, candidates for this position must qualify as a W2 candidate.

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