DEPARTMENT(S):  Customer Service REPORTS TO:  Supervisor, Customer Service FLSA STATUS:  Non-Exempt SALARY GRADE:  C - $41,000 - $53,000 

JOB SUMMARY

The Customer Service Representative (CSR) is the first line of contact for CalOptima members and providers. The incumbent will assist members and providers with questions related to the Medi-Cal programs for Orange County. Resolves member inquiries and complaints fairly and effectively. This position will provide information regarding eligibility, enrollment, benefits and services to CalOptima eligible members and providers.

POSITION RESPONSIBILITIES:

• Addresses member inquiries, questions and concerns in all areas including enrollment, claims, benefit interpretation, and referrals/authorizations for medical care.
• Verify member eligibility, claim and authorization status for providers.
• Responsible for thorough follow-up and completion of all member, and provider inquires or requests
• Responsible for accurate, complete and correct documentation into Facets regarding all issues, and/or inquires, complaints and grievances.
• Function efficiently and productively in a high-volume telephone call center.
• Maintain departmental productivity and quality standards.
• Provide follow-up assistance as needed.
• Route escalated calls to the appropriate Member Liaison, Supervisor or Call Center Manager
• Refer issues to health networks and/or make recommendations for further contacts within CalOptima.
• If designated, responsible for processing all member transportation request within 1 business day of receipt and coordinating all aspects of the process with clinic, provider and member as appropriate or necessary
• Adhere to company and departmental policies and procedures.
• Assists Members with CalOptima’s Member Web Portal registration and technical support. Other duties or projects as assigned by management.

KNOWLEDGE & ABILITIES:  

• Establish and maintain effective interpersonal relationships with members, coworkers and the public.
• Function efficiently and productively in a high-volume telephone call center.
• Effectively communicate both in writing and verbally.
• Learn procedures and regulations governing member eligibility and the terminology and documents used while remaining knowledgeable of CalOptima/Medi-Cal benefits and procedures.
• Understand and follow oral and written directions.
• Hear and speak well enough to converse on the telephone and in person.
• Perform work requiring repetitive use of hands, arms or shoulders (e.g. keyboarding, typing, etc.).
• Effectively utilize computer and appropriate software and interact as needed with CalOptima Information Systems.

EXPERIENCE & EDUCATION:

• High school diploma or equivalent required.
• 6 months call center experience with high call volumes or customer service experience analyzing and solving customer problems required. HMO, Medi-Cal/Medicaid and health services experience preferred.
• Bilingual in English and in one of CalOptima's defined threshold language is required.

KNOWLEDGE OF:

• Principles and practices of managed health care, health care systems, and medical terminology.
• Principles and techniques for handling customer service issues.
• Personal computers, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
• Understanding of the CalOptima program.
• Customer service principles and practices.

CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

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If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.  You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.

Required Skills Required Experience

Under the supervision of the Clinical Director, the Registered Nurse oversees the care of patients in the General Inpatient Hospice Unit and provides skilled professional nursing care to them, their families and caregivers as prescribed by the physician and in compliance with the Hospice Medicare Conditions of Participation, Pennsylvania Hospice licensure laws and agency policies and procedures. Provides the initial assessment and comprehensive nursing assessment of patient needs and collaborates to develop the Hospice Interdisciplinary Team (IDT) plan of care. Implements the plan of care and reevaluates and revises the plan of care relative to the patient’s nursing needs to provide appropriate, comprehensive and responsive goals and interventions. Works closely with other members of the IDT to ensure all patient and family care needs are being met. Provides supervision to Hospice LPNs/Aides/Volunteers.

+--------------------------------------------------------------------------+ | CHARACTERISTIC DUTIES & RESPONSIBILITIES OF JOB: | | | | E = Essential Element                      NE = Nonessential Element | +--------------------------------------------------------------------------+ | 20%  (E)  Seeks and obtains sufficient information necessary to function | | effectively in the Hospice setting where the patient/family/caregiver is | | receiving care. | | | | Conducts initial assessment, including physical, emotional and | | psychosocial aspects, of patient/family/caregiver in a thorough, | | accurate, compassionate and timely fashion. | | | | Utilizes the nursing body of knowledge to provide leadership and | | guidance to the IDT in formulating and individualizing the | | interdisciplinary plan of care to include problem identification, | | interventions and goals to address palliative comfort measures for the | | terminally ill patient, family and caregiver. | | | | Contributes to identifying both active and potential needs of the | | patient and his/her family, which may affect the plan of care. | | | | Consistently collaborates with the physician to plan and implement the | | medical and nursing plan of care. | | | | Reviews the nursing component of the comprehensive interdisciplinary | | plan of care with the IDT. Communicates in writing in the clinical | | record and verbally with the IDT to coordinate interventions and ensure | | continuity of care. | | | | Facilitates and participates in the IDT care conference and contributes | | to patient care planning. | +--------------------------------------------------------------------------+ | 20%  (E)  Provides nursing interventions and appropriate preventative | | and therapeutic nursing procedures | | | | Collaborates with IDT members to provide continuous assessment of | | assigned patients; interprets findings, initiates appropriate | | therapeutic actions and evaluates the results of these actions. | | | | Accepts responsibility of assignment to perform a specialized procedure | | only when qualified with specialty training, proven competency, clinical | | background and expertise in the specialty area. | | | | Works in cooperation with family/caregiver and IDT members to meet the | | physical and emotional needs of the patient/family/caregiver. | | | | Provides appropriate information and explanation to the patient and | | patient’s family. | | | | Facilitates patient and family education to promote continuity of care | | and optimal patient/family outcomes for quality of life as defined by | | the patient/family/caregiver. | | | | Demonstrates expertise in the utilization of all IDT members including | | volunteers and community resources. | | | | Fulfills productivity requirements on an average daily census basis as | | determined by acuity level and Executive Director. | | | | Documents accurate, complete and relevant clinical notes regarding | | patient’s condition and care given. Maintains documentation on a timely | | basis. | | | | Assesses the dietary/nutritional needs of Hospice patient and provides | | appropriate interventions relative to nutritional intake as the | | patient’s condition progresses | +--------------------------------------------------------------------------+ | 20%  (E)  Acts as a mentor to other personnel by participating in | | orientation and assisting, as needed,  with field training and inservice | | education to contractors and referral sources. | | | | Participates in formal and informal inservices and patient care | | conferences to promote professional growth of all interdisciplinary team | | members. | | | | Teaches the patient, family and/or caregiver regarding the progression | | of the disease process and self-care techniques as appropriate, | | including providing medication, dietary/nutritional counseling support | | and other instructions as ordered by physician, recognizing and | | utilizing opportunities for health counseling. | | | | Supervises Hospice Aides/Homemakers every fourteen (14) days per | | Medicare Conditions of Participation. | | | | Evaluates effectiveness of educational experiences and teaching methods | | in order to promote ongoing professional development of Hospice staff | | and quality patient outcomes for patients, families and caregivers | +--------------------------------------------------------------------------+ | 10%  (NE)  Manages daily visits and assignments for maximum efficiency. | | | | Bases visit frequencies according to individual patient needs and | | acuity. | | | | Reviews visit frequencies at least weekly and alters to meet patient | | needs and acuity. | | | | Coordinates patient care visits with all IDT members in order to utilize | | manpower resources and provide optimal patient care. | +--------------------------------------------------------------------------+ | 10%  (NE)  Ensures adequate and appropriate inventory of supplies and | | equipment for the provision of patient services, and promotes the | | efficient use of equipment and supplies. | | | | Maintains confidentiality in patient-related matters. | +--------------------------------------------------------------------------+ | 5%  (NE)  Demonstrates behavior appropriate to a role model and leader, | | including adhering to the agency code of conduct. | | | | Demonstrates creativity and critical thinking ability when participating | | in IDT conferences, developing patient care plans, or completing | | assigned projects. | | | | Assumes leadership role to facilitate interdisciplinary care | | coordination and collaboration. | | | | Functions without supervision, utilizing time constructively and | | organizing assignments for maximum productivity | +--------------------------------------------------------------------------+ | 5%  (NE)  Introduces self and clarifies role to | | patient/family/caregiver, physicians, nursing facility staff and other | | referral sources. | | | | Recognizes and responds appropriately to verbal and non-verbal cues. | | | | Communicates effectively with all members of the IDT by: | | | | 1. Defending and supporting peer/team decisions and actions. | | 2. Asserting self with tact. | | | | - Supporting collaboration and team decisions/plans. | | | | 1. Maintaining open communication. | | 2. Offering suggestions and criticisms constructively. | | 3. Asking questions and sharing information during IDT conferences and | | nursing facility care conferences. | | | | Relates complete and pertinent information in verbal and written | | communication. Maintains clinical records, statistics, and reports as | | prescribed and in compliance with local, state and federal laws. | | | | Initiates and maintains open and effective communication with supervisor | | as well as members of the IDT as evidenced by improved patient outcomes. | +--------------------------------------------------------------------------+ | 2%  (NE)  Coordinates travel time for visits and manages a caseload to | | deliver care in a cost-effective manner that demonstrates an | | understanding of Hospice reimbursement methodologies. | +--------------------------------------------------------------------------+ | 2%  (NE)  Ensures proper maintenance of records per agency guidelines.  | | Complies with local, state and federal laws, Medicare Hospice Conditions | | of Participation and agency policies and procedures. | +--------------------------------------------------------------------------+ | 2%  (NE)  Participates in the Quality Assessment/Performance Improvement | | (QAPI) process by finding opportunities for continuous monitoring and | | identification of patient outcomes, intra/interdepartmental and | | environmental concerns. Participates in clinical record review. | +--------------------------------------------------------------------------+ | 2%  (NE)  Assists and serves on committees and projects as requested.  | | Participates in staff meetings, department meetings, Hospice IDT | | meetings, inservices, committees and other related activities as | | required. | +--------------------------------------------------------------------------+ | 1%  (NE)  Participates in evening/weekend on-call as required, | | conducting on-call services in a clinically competent and responsive | | manner. | +--------------------------------------------------------------------------+ | 1%  (NE)  Performs other duties as assigned. | +--------------------------------------------------------------------------+

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