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Member Services Representative - Medi-Cal

Date: Apr 17, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 4826 


Position Summary/Position


Member Services Representative is responsible for being a devoted and compassionate advocate for Members when assisting with maximizing their benefits, navigating the healthcare system and reaching their optimal health. Responsible for providing guidance and answering questions from Members about their benefits and medical claims, as well as educating Members about wellness programs. Assisting Members in assessing tools available to help guide decision-making about complex matters related to their wellbeing. Facilitate the Members selection and access to in-network healthcare providers. Collaborate with inter-departments to ensure Member needs are met. 

Major Functions (Duties and Responsibilities)

1. Provide Member’s with health plan education in regard 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 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 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

Leading: Self

Experience Qualifications


1 year of Customer Service experience with a high level of patience when analyzing and resolving Member issues. A minimum of 1-year call center experience. Microsoft Windows applications experience.

Preferred Experience


HMO or Managed Care Experience preferred. A minimum of 1-year call center experience in a customer services setting preferred. Medi-Cal program and benefit requirements experience desired. May substitute with 2 years of experience in a medical or hospitality setting.

Education Qualifications


High school diploma or GED required.

Drivers License Required


Knowledge Requirement


Knowledge in Medical terminology preferable.

Skills Requirement


Proficiency in Microsoft Office Suite. Typing- Minimum 35 wpm, good grammar and spelling skills are necessary. Excellent oral communication skills.

Abilities Requirement


Ability and willingness to learn and follow direction in a fast-paced call center environment. High level capacity to multitask. Candidate must feel comfortable with learning and using computer programs. Excellent punctuality and attendance is required. Ability to remain courteous when dealing with difficult or challenging callers is critical to this position. Ability and desire to handle 45-50 calls per day, excellent multi-tasking skills. Positive Attitude and ability to work in a team setting.   High level of patience. 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.

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.


Starting Salary: $37,440.00  - $41,184.00  

Pay rate will commensurate with experience


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