CenCal Health
Member Services Specialist - Medicare
CenCal Health - Santa Barbara, California, United States, 93110
Work at CenCal Health
Overview
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Overview
Job Details
Job Location Main Office - Santa Barbara, CA
Position Type Full Time
Job Category Member Services
Description
Candidates for this position must reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties) or be willing to relocate to the area upon hire. As a community-facing role, a local presence is essential to effectively engage with and serve our community. Please note that relocation assistance may be available.
Central Coast Salary Range:
$36.76 - $53.31 per hour
Job Summary
The expectation for the Member Services Specialist is to provide robust customer service for CenCal Health's CareConnect members and its provider network that aligns with the Plan's strategic goals and Mission. In this role, the Member Services Specialist provides proactive and compassionate support to CenCal Health members. This role supports the coordination of care, assists with navigating healthcare benefits, and serves as a critical liaison between members, providers, and internal departments. The position ensures access to services such as Primary Care Provider (PCP) selection, transportation, interpreters, mental health coordination, pharmacy inquiries, and care continuity. It also supports grievance and appeal intake, system navigation, and education regarding health plan benefits and resources.
Duties & Responsibilities Provide robust customer service in a queue environment, addressing member inquiries about Medicare and Medi-Cal integrated benefits and supplemental benefits, providers, referrals, authorizations, claims, transportation, interpretation and translation needs, alternative formats needed and intake of grievances/appeals. Hours of operation for the CareConnect Call Center include 8:00am-8:00pm, 7 days a week and must be able to work a rotating schedule to cover the hours of operation under a standard 40-hour work week. Assist with member navigation of healthcare benefits and services, including appointment scheduling assistance, interpreter coordination, how to obtain health education materials, key vital documents such as Evidence of Coverage (EOC), Provider Directories, Formulary guidance and other requests as needed. Provide outbound member education and outreach, such as new member orientations, deeming period assistance to help members restore lost Medi-Cal or Medicare coverage, and coaching regarding healthcare access, no-shows, or disruptive behaviors. Act as a liaison between members and internal departments (e.g., Care Coordination, Disease Management, Pharmacy, Health Education, Quality Management) to ensure appropriate referrals and follow-through. Triage and coordinate continuity of care intake. Coordinate support with external agencies such as CMS, DSS, SSA, Tri-Counties Regional Centers, Public Health Departments, California Children's Services, and other community-based organizations. Educate members on healthcare benefits, co-pays, premiums and co-insurance, provider networks, and available resources. Assist members with inquiries regarding the member portal, website and any outside supplemental benefit vendor accounts. Document all contacts, referrals, and follow-ups in the appropriate systems, and ensure timely and accurate data entry. Support departmental compliance and quality assurance activities. Assist with resolving issues related to other health coverage, eligibility and demographic updates as needed. Perform other duties and/or special projects as assigned by the Supervisor, Manager, and/or Director.
Qualifications
Knowledge/Skills/Abilities Proven excellence in customer service experience and strong orientation skills Strong oral and written communication, interpersonal/relationship-building skills Excellent attention to detail with the ability to break down complex information into actionable insights. Demonstrated analytical skills: able to collect, interpret, and evaluate data to support decision-making and problem-solving. Applies sound judgement within the scope of the position in evaluating evidence, identifying patterns, and making informed decisions considering both short-and long-term impacts. Knowledge of CenCal Health and the Medi-Cal and Medicare Dual Special Needs Programs (D-SNP) or Medicare Advantage programs is strongly preferred High proficiency with Microsoft Office Suite and internal systems (e.g., QNXT, MyQNXT, MEDSLite, CalSAWS, and MedHok (MHK) for grievances, appeals, authorizations and case management assistance look up and assistance. Ability to work independently with minimal supervision and manage competing priorities in a fast-paced environment Demonstrated problem-solving skills with a proactive and solution-oriented approach. Strong organizational skills and time management skills, with the ability to multitask effectively.
Education & Experience
Required: Experience working in a healthcare call center, preferably Medicare Advantage or specific D-SNP experience, human services, or public assistance environment in an administrative capacity, directly supporting the population utilizing medical services (e.g., medical receptionist, regional center coordinator, patient advocacy, customer service representative, or related roles).
Preferred: Bilingual in Spanish
Job Location Main Office - Santa Barbara, CA
Position Type Full Time
Job Category Member Services
Description
Candidates for this position must reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties) or be willing to relocate to the area upon hire. As a community-facing role, a local presence is essential to effectively engage with and serve our community. Please note that relocation assistance may be available.
Central Coast Salary Range:
$36.76 - $53.31 per hour
Job Summary
The expectation for the Member Services Specialist is to provide robust customer service for CenCal Health's CareConnect members and its provider network that aligns with the Plan's strategic goals and Mission. In this role, the Member Services Specialist provides proactive and compassionate support to CenCal Health members. This role supports the coordination of care, assists with navigating healthcare benefits, and serves as a critical liaison between members, providers, and internal departments. The position ensures access to services such as Primary Care Provider (PCP) selection, transportation, interpreters, mental health coordination, pharmacy inquiries, and care continuity. It also supports grievance and appeal intake, system navigation, and education regarding health plan benefits and resources.
Duties & Responsibilities Provide robust customer service in a queue environment, addressing member inquiries about Medicare and Medi-Cal integrated benefits and supplemental benefits, providers, referrals, authorizations, claims, transportation, interpretation and translation needs, alternative formats needed and intake of grievances/appeals. Hours of operation for the CareConnect Call Center include 8:00am-8:00pm, 7 days a week and must be able to work a rotating schedule to cover the hours of operation under a standard 40-hour work week. Assist with member navigation of healthcare benefits and services, including appointment scheduling assistance, interpreter coordination, how to obtain health education materials, key vital documents such as Evidence of Coverage (EOC), Provider Directories, Formulary guidance and other requests as needed. Provide outbound member education and outreach, such as new member orientations, deeming period assistance to help members restore lost Medi-Cal or Medicare coverage, and coaching regarding healthcare access, no-shows, or disruptive behaviors. Act as a liaison between members and internal departments (e.g., Care Coordination, Disease Management, Pharmacy, Health Education, Quality Management) to ensure appropriate referrals and follow-through. Triage and coordinate continuity of care intake. Coordinate support with external agencies such as CMS, DSS, SSA, Tri-Counties Regional Centers, Public Health Departments, California Children's Services, and other community-based organizations. Educate members on healthcare benefits, co-pays, premiums and co-insurance, provider networks, and available resources. Assist members with inquiries regarding the member portal, website and any outside supplemental benefit vendor accounts. Document all contacts, referrals, and follow-ups in the appropriate systems, and ensure timely and accurate data entry. Support departmental compliance and quality assurance activities. Assist with resolving issues related to other health coverage, eligibility and demographic updates as needed. Perform other duties and/or special projects as assigned by the Supervisor, Manager, and/or Director.
Qualifications
Knowledge/Skills/Abilities Proven excellence in customer service experience and strong orientation skills Strong oral and written communication, interpersonal/relationship-building skills Excellent attention to detail with the ability to break down complex information into actionable insights. Demonstrated analytical skills: able to collect, interpret, and evaluate data to support decision-making and problem-solving. Applies sound judgement within the scope of the position in evaluating evidence, identifying patterns, and making informed decisions considering both short-and long-term impacts. Knowledge of CenCal Health and the Medi-Cal and Medicare Dual Special Needs Programs (D-SNP) or Medicare Advantage programs is strongly preferred High proficiency with Microsoft Office Suite and internal systems (e.g., QNXT, MyQNXT, MEDSLite, CalSAWS, and MedHok (MHK) for grievances, appeals, authorizations and case management assistance look up and assistance. Ability to work independently with minimal supervision and manage competing priorities in a fast-paced environment Demonstrated problem-solving skills with a proactive and solution-oriented approach. Strong organizational skills and time management skills, with the ability to multitask effectively.
Education & Experience
Required: Experience working in a healthcare call center, preferably Medicare Advantage or specific D-SNP experience, human services, or public assistance environment in an administrative capacity, directly supporting the population utilizing medical services (e.g., medical receptionist, regional center coordinator, patient advocacy, customer service representative, or related roles).
Preferred: Bilingual in Spanish