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Member Services Representative - Medi-Cal

Date: Aug 10, 2019

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 3110 


Position Summary/Position

Under the direction of the Call Center Member Services Supervisor, will anticipate, document and respond to Members’ needs and represent Inland Empire Health Plan in a friendly and professional manner.  The MSR I will work in concert with other departmental Team Members to achieve 5 Star Service and call center goals.

Major Functions (Duties and Responsibilities)

1.Provide Member’s with health plan education in regards to and Medi-Cal benefit coverage, including understanding coordination of benefits and eligibility rules.
2.Meet IEHP and Member Services Call Center standard and policy requirements.   This includes, but is not limited to the following; successful completion of Member Services Training, active participation in continuous training, use telephone system and other IEHP equipment appropriately and for professional reasons only, follow required call scripts and adhere to Attendance/Punctuality and Dress Code policy.
3.Provide superior service that delights caller in all aspects of the interaction including:
a.Strive to assist caller on the first point of contact.  Demonstrate a high level of patience and respect; avoid distractions to ensure each caller is assisted promptly and appropriately; follow call handle standards and objectives.
b.Assist with Member primary care/facility assignments, selections and changes; health care options liaison; health education advisory; supply eligibility status of Members to providers
c.Member education including tagging, material request, programs, ordering ID cards and accessing services.
d.When necessary present cases to Member Services Management Team and work with other departments to resolve Member and/or Provider inquiries and/or issues.  Including but not limited to transportation requests, interpreter requests, referrals questions/concerns, re-directions, Behavioral Health and Pharmacy inquiries.
e.Document accurately while speaking with the caller.  Complete Member Satisfaction Surveys and Assessments, as needed.  Over 100% call documentation is required
f.Proper and timely intake of Member grievances
4.Coordinate telephonic translation of calls when Members do not speak English or Spanish.
5.Participate in Member Services Department meeting, which are held approximately twice a month on a Wednesday from 7:00am to 8:00am. In addition, responsible for attending monthly TQM which are conducted from 7:00am to 8:00am and any Team Meetings as scheduled.
6.Efficient problem solving, time management, initiative, and focus skills requiring minimum supervision and guidance.
7.High technological aptitude with efficient adaptability to diverse and changing systems and business conditions.
8.Ensure key performance indicator goals are met monthly (Quality Assurance, Average Handle Time, Adherence)
9.Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP's policies and procedures relating to HIPAA compliance. Demonstrate a commitment to understand and adhere to the Regulatory requirements as they relate to the business unit.
10.Preserve Member’s confidentiality by authenticating callers (submitting guardianship documents for verification, establish guardianship alerts, authentication passwords and confidentiality alerts as needed).
11.Demonstrate a commitment to LEAN by participating in process improvement projects and RIE Events/Huddles.  Act as an owner and submit ideas on efficiency gains.
12.Assist Members with navigation, troubleshooting and password reset with IEHP Website and Web Portal.
13.Assist with tracking trends within the department and escalating this information to management.
14.Ensure timely work action on all Activities and Cases.  Submit daily updates on aged Activities or Cases to management.
15.Review call monitors recordings and develop self action plans to improve quality assurance scores.
16.Maintain knowledge of other departments and the roles they play in Member Services standard work processes, to ensure proper handling and tasking of calls.
17.Comply with IEHP Telecommuting Agreement and requirements, as applicable.

Supervisory Responsibilities

Not Responsible

Experience Qualifications

Bilingual (Spanish) a plus. Medi-Cal program and benefit requirements experience desired. HMO or Managed Care Experience preferred. A minimum of 1 year call center experience in a customer services setting preferred. May substitute with 2 years of experience in a medical or hospitality setting.  Excellent punctuality and attendance is required. Significant customer service experience with prior experience in handling problems and complaints with a high level of patience. Ability to remain courteous when dealing with difficult or challenging callers is critical to this position. Experience in learning and following standards and procedures.

Education Qualifications

Possession of a high school diploma or equivalent.

Professional Certification

Professional Licenses

Knowledge Requirement

Ability and desire to handle 45-50 calls per day, excellent multi-tasking skills. Positive Attitude and ability to work in a team setting.     Knowledge in Medical terminology preferable.

Abilities Requirement

 Ability to work independently within specified time constraints. Ability to adapt and perform duties efficiently when unexpected changes arise. Adherence to specific work schedule is required. Works well in a fast-paced environment.

Other Characteristics

Commitment to Team Culture:The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions

Communication with IEHP Members and providers, which includes intensive telephone use as well as data entry involving computer keyboard and screens.

Physical Requirements


Starting Salary: $15.83 per hour


Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles

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