A Healthcare Customer Service Representative responds to customer inquiries about healthcare and provides information about healthcare plans, providers, policies and coverage. Assists customers with questions about healthcare insurance and premiums. Keeps records of customer communications and transactions.
Chula Vista, CA Job Details Full-time $24.96 - $27.46 an hour 23 hours ago Qualifications Spanish English Driving Full Job Description
POSITION SUMMARY
The HEDIS Outreach Specialist is responsible for improving quality performance outcomes through member outreach, provider coordination, quality gap closure initiatives, medical record review, HEDIS reporting support, incentive program administration, and Initial Health Assessment (IHA) outreach activities. Utilizes persuasive communication and motivational interviewing techniques to encourage members to complete preventive and chronic care services, coordinates appointments with PCPs and specialists, handles complex member inquiries, and supports quality improvement projects through effective navigation of Epic, NextGen, eClinicalWorks, and other EHR systems.
COMPLIANCE WITH REGULATIONS
Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal.
RESPONSIBILITIES
Supports -intra departmental workflows by establishing and maintaining effective communications with internal and external contacts. Conducts high-volume outreach campaigns to close HEDIS and quality care gaps including Annual Wellness Visits, Mammograms, Pap Smears, Prenatal/Postpartum Care, Immunizations, and other preventive services. Coordinates member appointments directly with PCP offices, specialists, facilities, laboratories, imaging centers, and contracted vendors. Utilizes persuasive communication techniques to educate and motivate members to complete recommended healthcare services. Performs Initial Health Assessment (IHA) outreach, scheduling, follow-up, and coordinate activities for our DSNP and CSNP members which help improve our risk adjustment scores. Completes annual HEDIS abstraction training, pass competency testing, perform chart reviews, and participates in medical record extraction activities. Retrieves, scans, organizes, and prepares medical records for HEDIS reporting, abstraction, and audit purposes. Maintains member and physician confidentiality at all times Navigates Epic, NextGen, eClinicalWorks, and other EHR platforms to identify and retrieve documentation supporting quality measure compliance. Provides appropriate HEDIS correspondence to members as necessary. Handles calls related to member incentive programs, eligibility determinations, portal registration, document uploads, and complaint resolution. Assists members with portal account creation and navigation, including uploading supporting documentation. Research and completes special projects assigned by the HEDIS Manager to improve quality performance and increase measure compliance. Identifies operational issues preventing the delivery of good customer service by documenting and referring these to Customer Services management for follow-up and resolution. Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested. Maintains customer confidence and protects company operations by keeping information confidential. This position requires occasional travel within the San Diego County area. Meets or exceeds departmental productivity, quality, outreach, appointment scheduling, quality gap closure, medical record retrieval, and member service performance standards established by management. Based on weekly outreach reports, is responsible for placing a minimum of 45 outbound calls per hour with an expected successful contact rate of at least six (6) members per hour. Productivity standards may include, but are not limited to, outbound call volume, successful member contacts, appointment scheduling conversion rates, quality gap closure rates, incentive call resolution metrics, medical record review accuracy, documentation quality, completion of special projects, and achievement of departmental performance goals. Contributes to the team effort by accomplishing related duties as assigned or requested.
EDUCATION
High school diploma or equivalent.
EXPERIENCE/SKILLS
Ability to influence, educate, and motivate members to complete healthcare services and close quality care gaps. Experience coordinating care and scheduling appointments with providers and healthcare vendors. Proficiency navigating multiple EHR platforms including Epic, NextGen, eClinicialWorks, and other provider systems. Ability to effectively manage difficult members interactions while maintaining exceptional customer service. Two of customer service experience or outreach experienced preferred. Medical terminology preferred. Bilingual English/Spanish required. Excellent communication and interpersonal skills. Strong analytical, research, organizational, and problem-solving skills. Ability to review medical records and identify documentation supporting quality measure compliance. Working knowledge of
HEDIS, CMS STAR
rating, quality improvement programs, and managed care operations preferred.
PHYSICAL REQUIREMENTS
Driving within San Diego County Prolonged periods of sitting. Extensive use of telephone. May be required to work evenings and/or weekends. The above statements describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All qualified applicants will receive consideration for employment based on merit, without regard to race, color, religion, sex, national origin, disability, protected Veteran Status, or any other characteristic protected by applicable federal, state, or local law.
