1 jobs found in Pomona

    Job Description - Customer Services Concierge Support, Intermediate (Bilingual) (200018P) Job Description   Customer Services Concierge Support, Intermediate (Bilingual)   -   200018P   At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We’re excited to share Blue Shield of California has received awards and recognition for – LGBT diversity, quality improvement, most influential women in corporate America, Bay Area’s top companies in volunteering & giving, and one of the world’s most ethical companies. Here at Blue Shield of California, we’re striving to make a positive change across our industry and the communities we live in – Join us!   Description   Customer Service Concierge Support (Bilingual)   Member Services: Services plan members by addressing inquiries through different channels (e.g., live web-based applications, telephone, email and walk-in), resolving issues, and educating members. Ensures proper member services procedures and works towards providing the best customer experience     Customer Service Concierge Support - Assist members in consultation and referral to programs available to the member by resolving incoming calls concerning members eligibility, benefits, provider information, clinical and pharmacy needs.   Essential Responsibilities: Assisting walk-in members with issues such as eligibility, benefits, provider information, clinical and pharmacy needs.   This role is on-site (not remote).   Composes routine and non-routine correspondence to answer benefits/provider inquiries in writing. Coordinates membership changes such as members primary care physician. Comprehensive resolution of pharmacy calls concerning benefit coverage, co-pays, formulary coverage, vacation overrides, and utilization management requirements. Performs inventory reduction, routine to mid-level, (i.e. member inquiries, may initiate claim adjustments, responds to emails, etc.) Participate in quality and efficiency workgroups to continuously improve quality member/customer satisfaction as requested. Assume Medical Management Clinical Support Coordinator duties to create clinical case to transfer to the clinical staff. Analyze available programs, determine program eligibility and connect member to appropriate Blue Shield of California vendors, Health Advocates, Social Workers, Pharmacy Techs, and Pharmacists. Verify the member is included in or targeted for any outreach or care gap programs and connect members to programs or services when appropriate. Triage cases for assignment to the Shield Concierge Case Management, Behavior Health, Health Management Programs and/or Member Outreach programs and document the status in appropriate systems. Elevated level of empowerment to resolve disputes prior to escalating to Appeals and Grievances. Proactively engages member with their wellness plan options.  Enhanced knowledge of medical terminology. Triage cases to RNs when the case exceeds extension of authority and the criteria is met. Collaborates with the provider to ensure Continuity of Care is maintained on behalf of the member. Provide prescription related benefit coverage (e.g. explanation of coverage or benefit summary related): Provide prescription co- pays. Provide prescription formulary coverage information and utilization management requirements using web posted printed formulary. Provide deductible and max out of pocket information. Provide status of a prior authorization requests. Assist members may when and how to appeal a coverage decision. Provide a brief description of coverage denial reason and alternatives as listed in the printed formulary. Perform prescription claim overrides. Other duties as assigned. For bilingual jobs, Spanish language proficiency as demonstrated by successful completion of an oral language proficiency test. Other duties as assigned.       Qualifications   For bilingual jobs, Spanish language proficiency as demonstrated by successful completion of an oral language proficiency test. Requires basic job knowledge of systems and procedures obtained through prior work experience or education. Requires minimum of 3 years of experience. May require vocational or technical education in addition to prior work experience.         James