Established in 1997, San Francisco Health Plan (SFHP) is a an award winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco county. San Francisco Health Plan is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 142,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services. SFHP was designed by and for the residents it serves, and takes great pride in its ability to accommodate a diverse population that includes young adults, seniors, and people with disabilities.
THE EXCITING CHALLENGE
The Member Data Coordinator is responsible for the accuracy of member data pertaining to eligibility, PCP assignments, coordination of benefits, and other related member coverage. Duties include correcting member eligibility in QNXT, resolving eligibility problems for providers/vendor groups, assigning PCP for members, identifying other health coverage of members by making outreach calls, and achieving organizational and departmental goals.
DUTIES & RESPONSIBILITIES
- Manually corrects eligibility discrepancies within the required time frame.
- Handles eligibility discrepancy issues for vendor groups and network providers, and finds resolutions.
- Manually assigns and reassigns a PCP, and adds attributes for members.
- Processes Healthy Workers applications.
- Finds information of member’s other health coverage and enters it to DHCS website. Follows up until eligibility is changed.
- Contacts Medi-Cal to correct information listed in MC website.
- Manages COB information for members with dual coverage.
- Coordinates benefits by outreaching potential Medicare members and members who have other primary insurance.
- Outreaches Healthy Workers members who are over 65 years old and have dual coverage with Medi-Cal and helps them enrolling to Medi-Care.
- Works with other health coverage vendors to update QNXT on member’s eligibility and coordinates benefits.
- Identifies primary and secondary eligibility on VA cases.
- Supports Customer Service Department for phone back-up and administrative duties.
- Comprehends and keeps abreast of all information of the job, including but not limited to new processes, procedures, program or plan requirements, and new HIPAA requirements.
- Capable of accessing and utilizing information resources to provide the most accurate and thorough responses, in accordance with departmental policies.
- Works effectively and efficiently in a team with minimal supervision in a diverse and performance based environment where productivity is measured.
- Maintains records and regular written reports as needed.
- Performs duties requested by the supervisor.
- High school graduate or GED; Bachelor’s degree desired
- Experience in member eligibility information and verification highly desireable
- Bilingual in English and Spanish or Cantonese highly desirable
- Knowledge of QNXT system especially with the Member Module desired
- Extensive skill with call center environment and ACD system desired
- Demonstrates familiarity and understanding of California managed care and medical terminology preferred
- Proven organizational skills with excellent follow-through and the ability to multi-task and implement program goals and objectives in an effective and efficient manner
- Ability to interpret and comply with complex rules and regulations
- Computer competency, including Microsoft, Excel, Word, Outlook, Access, SharePoint or other database applications
- Strong verbal and written communication skills with understanding of confidentiality related to sensitive information
- Experience in providing outstanding customer service including the ability to deliver unfavorable information in a helpful and empathic fashion, without deviating from Plan or program policy
- Ability to produce accurate and precise work, detect and resolve discrepancies while meeting deadlines.
- Ability to work effectively, independently, and as part of a team
- Strong time management and project management skills with multi-tasking abilities
- Advanced analytical capability and problem solving skills with the ability to formulate and communicate recommendations for improvement
- Proven understanding of and ability to process confidential information and personal health information with competence, care and discretion
- Exemplary interpersonal and customer service skills
- Demonstrates professionalism, poise, tact, and diplomacy in interactions with others
- Possession of consistent good judgment, organization and prioritization skills, and time management techniques
- Maintains calm, welcoming, and professional manner
- Proven successful work experience with: “in-person” consultations/intake meetings, surveys, etc. with people of diverse backgrounds; competency in using a multi-line telephone system
- Demonstrates successful work experience with and/or ability to efficiently navigate the SFHP computer system while on the multi-line phone, to locate and/or record information about a participant, employer or provider accurately and timely
San Francisco Health Plan is an Equal Opportunity Employer (EOE) M/F/D/V
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.