Coordinate multi-departmental (Member Services, PNO, Claims, UM, Sales, Medicare enrollment and QM) 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 and L. A. Care guidelines. Ensure to follow departmental guidelines/matrixes for all processes. Urgent Complex cases will be handled within 24hrs. All others within 48hrs. (30%)
Work as a navigator to our Medicare Line Of Business (LOB): A. Ensure to meet deadline for completion of Welcome Calls; B. Ensure to follow through on all cases forwarded to other areas for assistance; C. Document all transportation services provided to each member. Ensure to confirm appointment and authorization; D. Coordinate/assist with all other departments regarding Medicare Services; E. Thorough Reinstatement of enrollment of members whose disenrollment are questionable; F. Identify and complete Organization and Coverage Determination for timeliness and resolution; G. Ensure proper Guidelines are followed for Medicare disenrollment request; H. Ensure to complete all BAE and/or LIS request. (25%)
Identify potential quality of care issues and referral to QM Department, through calls received from our Call Center and other internal customers. (10%)
Handle disenrollment's requests from 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. (5%)
Work with Compliance Department regarding suspected fraudulent activities received through the L.A. Care hot line and the Call Center personnel. (5%)
Communicate with collection agencies, billing business offices regarding delinquent and problematic member accounts which includes 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 the appropriate languages. As requested review documents submitted by C&L to ensure proper translation and culturally sensitive materials for distribution to our members (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%)