Work Location: This will be a hybrid position (working from home and in the office). 

Under direct supervision, respond to HPSM member and provider inquiries by telephone and other communication channels, providing members with comprehensive support regarding health plan benefits and services. Acts as the primary point of contact for members, delivering prompt, accurate, and courteous assistance via telephone and other communication channels, whether for general inquiries, concerns, or information requests about HPSM programs, services, eligibility or benefits.

Duties & Responsibilities

Essential Functions:

• Handle inbound and outbound calls and other communications in a high-volume environment, providing excellent customer service and professionalism, in accordance with established policies and procedures, and meeting established performance and quality metrics.
• Adhere to established guidelines, call scripts, and resources to address member and provider inquiries; this includes maintaining the confidentiality of member information and complying with HIPAA and other relevant regulations. For non-routine inquiries, leverage available resources and expertise to resolve issues that fall outside standard protocols or HPSM’s defined scope.
• Resolve concerns accurately, promptly, professionally, and with cultural competence; ensure that explanations are appropriate to the member’s level of understanding and knowledge.
• Intake, handle and coordinate member grievances, appeals and billing issues, escalating to the Grievance and Appeals department, when necessary.
• Educate members and providers about eligibility, benefits, and the HPSM provider network; assist members in selecting or changing their primary care physician and provide accurate information about available providers and effective dates for PCP assignments.
• Use listening skills and judgment to appropriately categorize and accurately document all  interactions and follow-up actions regarding member and provider communications and activities in accordance with established guidelines.
• Refer members to appropriate community partner agencies based on their specific needs, including but not limited to Behavioral Health and Recovery Services, Aging and Adult Services, Legal Aid, Human Services Agency, and HICAP when applicable.
• Use strong professional judgement to determine when to escalate member or provider inquiries to other HPSM departments; share important information and collaborate with these teams to resolve issues, this includes referring members to health services for care coordination and guiding providers to specialists for help with complex claims or questions.
• Proactively seek opportunities to improve processes and enhance the overall member experience.
• Attend and actively participate in regular departmental meetings, training sessions, and coaching sessions as applicable.
• Cross train on a variety of tasks as requested, to ensure the continuity of HPSM operations within the Member Services department and other departments.

Secondary Functions:

• Conduct member outreach such as welcome calls and targeted member outreach calls as assigned.
• Participate in and represent HPSM professionally at health fairs, community partnerships, meetings, committees, and coalitions as assigned.
• Perform other duties as assigned.

Qualifications

The following represents the typical way to achieve the necessary skills, knowledge and ability to qualify for this position:

Education and experience equivalent to:

• High school diploma or GED.
• One (1) or more years’ experience in Customer Service or Call Center role, preferably in a health care or public-sector setting.
• Previous experience with managed care plans, Medi-Cal and Medicare programs, and working with underserved populations.

Knowledge of:

• Microsoft Office products including Word, Excel, PowerPoint and Outlook.
• Health insurance and medical terminology.
• Quality metrics relevant to a call center, and best practices for achieving them.

Skills:

• Bilingual skills in Spanish, Mandarin, Cantonese or Tagalog are preferred but not required.

Ability to:

• Work cooperatively with others.
• Work as part of a team and support team decisions.

• Communicate effectively, both verbally and in writing with various audiences and individuals of diverse backgrounds.
• Meet deadlines and adapt to changes in requirements/priorities for daily and specialized tasks.
• Develop and maintain strong professional relationships with a diverse range of people.
• Develop and proactively maintain up-to-date knowledge of relevant quality, regulatory and organizational guidelines.
• Utilize a personal computer, including strong typing proficiency and the ability to use various Microsoft Office products including Word, Excel, PowerPoint and Outlook.
• Perform problem research, use analytical skills, and effectively influence positive outcomes.
• Understand written policies and procedures and apply these requirements to day-to-day work.
• Maintain health information confidentiality and follow information privacy and security best practices.

Physical Requirements & Environmental Conditions of the Position

Activity/Physical Function

Not at all

33% or less

34% to 66%

More than 66%

Keyboarding/Repetitive Hand Use

X

Standing

X

Walking

X

Sitting

X

Speaking

X

Hearing

X

Seeing

X

Lifting/carrying up to 20 lbs.

X

Lifting/carrying 21 to 50 lbs.

X

Lifting/carrying over 50 lbs.

X

Pushing or pulling

X

Overhead Reaching

X

Climbing/Kneeling/Crawling

X

Exposure to Environmental Conditions

Not at all

33% or less

34% to 66%

More than 66%

High Temperatures (over 85 degrees)

X

Low Temperatures (under 50 degrees)

X

Wet or High Humidity

X

Sudden Temperature Changes

X

Noise – High Level

X

Noise - Vibrations

X

Hazards – Mechanical & Electrical

X

Fumes/Odors/Smoke/Gas

X

The Health Plan of San Mateo (HPSM) is an equal opportunity employer and is committed to providing equal employment opportunities to all applicants and employees without regard to race, color, religion, creed, political affiliation, sex, gender, gender identity or expression, pregnancy, childbirth and related medical conditions, marital status, registered domestic partner status, sexual orientation, age, ancestry, national origin, citizenship status, veteran or military status, disability, medical condition, genetic information, or any other characteristic protected by applicable federal, state, or local law. 

This policy applies to all aspects of employment, including recruitment, hiring, selection, placement, promotion, transfer, demotion, compensation, benefits, training, discipline, and termination. 

HPSM is committed to providing reasonable accommodations to qualified individuals with disabilities and to applicants and employees with sincerely held religious beliefs or practices, in accordance with applicable law. If you require an accommodation during the application or interview process, or in order to perform the essential functions of a position, please contact the HPSM recruiter to request assistance.