Salary Range:

$61,554 - $89,253 The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.

FLSA Status:

Non-Exempt Department:

Health Services Reports To:

Manager, Community Based Care Management Employee Unit:

Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521 GENERAL

DESCRIPTION OF POSITION

The Community Based Programs (CBP) Coordinator leads and participates in processes and projects to support and improve the operations of the Community Based Programs (CBP) team in alignment with organizational objectives, and in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements. In this role, the Coordinator supports the daily operations of CBP benefits, programs and strategies including serving as primary initial contact for specific referrals and authorization processes.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. Oversee the processes for referrals and authorizations, including processing the denial and disenrollment for Medi-Cal benefits under the CBP Team in accordance with state and federal regulatory requirements and SCFHP policies and procedures as set forth for each benefit Perform complete, accurate and consistent authorization processes including review of benefit eligibility and referrals, request and review of medical records and other documentation, as applicable, escalation to clinical staff or management for further determination, and process approval and denial letters or Notice of Action. Act as the primary initial contact for CBP referrals and communicate with internal departments for additional follow up as necessary and appropriate. Perform routine duties including accurate and consistent data entry into system software applications, managing and following up on call queues, and working to resolve member and provider inquiries in a timely manner. Serve as liaison with Grievance and Appeals (G&A) Department for support with CBP related reviews and resolution of member and/or provider issues submitted by G&A Ensure grievance and appeals cases are accurate and include the necessary elements for processing and resolving, giving special attention to those identified as \"Expedite\". Create clear and concise documentation in applicable system(s). Support needs of the CBP team including scheduling, coordinating and documenting meetings, maintaining records, generating mailing lists, setting up documents, onboarding staff and implementing other projects in support of CBP strategies. Support team staff on reviewing and providing input on member and provider facing materials, including program guides, training slides, and member information flyers Support management in the process of approving policies, as well as the upload and updating of policy and procedures to PolicyTech platform. Follow established Health Services policies and procedures and use available resources to respond to member and/or provider inquiries and resolve any concerns in an accurate, timely, respectful, professional and culturally competent manner Build and maintain expertise and understanding of managed care, SCFHP policies and procedures, department functions and processes and relevant regulatory requirements. Collaborate with team members on improvement efforts across-departments regarding quality improvement projects, optimization of utilization management, and member satisfaction Assist in gathering and processing data for internal required reports and analysis. Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions. Process written and verbal notifications of authorization determinations to members and/or providers within regulatory processing timeframes. Perform other duties as required or assigned.

REQUIREMENTS

- Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. High school diploma or GED. (R) Associate's degree or equivalent experience, training or coursework. (D) Minimum two years of experience in customer service, program operations, health services, or in a managed care or community based setting handling escalated or complex issues. (R) Knowledge of health plan benefits, process and operations. (D) Experience and comfort working with data entry and system software applications. Prior experience with public or nonprofit programs, Medi-Cal and/or Medicare programs and working with the underserved populations. (D) Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills. (D) Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or event. (R) Experience with SQL development language and/or Tableau. (D)

WORKING CONDITIONS

Duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

PHYSICAL REQUIREMENTS

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:

Mobility Requirements:

regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)

Lifting Requirements:

regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)

Visual Requirements:

ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)

Dexterity Requirements:

regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)

Hearing/Talking Requirements:

ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)

Reasoning Requirements:

ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)

ENVIRONMENTAL CONDITIONS

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