Member Care Navigator - Full-Time, hybrid, located in

Ontario, California Position Summary:

This position serves as a frontline representative in the Elite Health Plan (EHP) Call Center and helps prospective and current members understand their health plan, resolve service questions, and access covered care and benefits. The Member Care Navigator also provides routine administrative support to licensed agents and broker partners, including onboarding and certification follow-up, incoming broker inquiries, and issue routing. The position coordinates with members, providers, brokers, vendors, and internal departments in accordance with Centers for Medicare and Medicaid Services (CMS), state, privacy, and EHP requirements. This is a nonclinical role and does not provide medical advice, make coverage determinations, conduct field agent training, or provide sales guidance outside the position's authority. Job Responsibilities (include the following, but not limited to) :

Duties and Responsibilities:

Serve as a frontline Member Services representative and assist members and providers by telephone in a calm, patient, and professional manner. Respond to member inquiries through telephone, email, fax, web, and written correspondence regarding eligibility, benefits, access to care, referrals, authorizations, utilization of services, coordination of benefits, claims, billing, and grievances. Orient and educate new and existing members on how their health plan works, including benefits, the provider network, accessing care, referrals, authorizations, claims and billing, coordination of benefits, and member rights and responsibilities. Help members locate participating providers, pharmacies, and approved benefit vendors and coordinate access needs such as appointments, transportation, interpreter services, and follow-up on unresolved requests. Conduct welcome calls, benefit education, preventive-care reminders, and other approved member outreach activities. Identify barriers that may prevent a member from obtaining care and coordinate follow-up with Care Management, Utilization Management, Pharmacy, Claims, Enrollment, or other responsible departments. Work toward first-call resolution of complaints and service issues when appropriate; identify potential grievances and appeals and route them promptly to the Appeals and Grievances Department according to EHP procedures. Recognize urgent member needs, potential quality-of-care concerns, and matters outside the position's authority and escalate them to the appropriate department or supervisor. Document member contacts, actions taken, referrals, follow-up commitments, and outcomes accurately, completely, and timely in EHP systems in accordance with standard operating procedures. Use system tools to route tasks and triage calls to the appropriate internal department or outside entity; collaborate with members, providers, benefit vendors, and other insurers to support timely resolution. Meet or exceed applicable CMS and EHP standards for call-center timeliness, accuracy, accessibility, service quality, member satisfaction, and documentation. Use approved translation and accessibility vendors and resources in accordance with CMS requirements and EHP procedures. Respond to routine broker-support inquiries by telephone, email, and other approved channels using current EHP information and established procedures. Provide administrative assistance with agent onboarding and certification, including document follow-up, completion tracking, system access requests, and status updates. Document broker contacts and requests accurately and route licensing, contracting, commission, sales, compliance, or field-training matters to the responsible department or employee. Maintain current knowledge of member benefits, departmental operations, policies, procedures, workflows, and managed-care customer service practices. Protect personally identifiable information and protected health information and comply with HIPAA, federal and state requirements, and EHP privacy and security policies. Attend mandatory in-office and remote training, quality monitoring, team meetings, and process-improvement activities as required.

Other General Duties:

Assist with special projects as assigned. Apply company standards, policies, procedures, workflows, and authority levels when responding to internal and external customers. Complete other duties within the scope of the business and position. Qualifications /

Skills:

Bi-Lingual:

Professional proficiency in English and Mandarin or Korean required. High school diploma or equivalent. At least two years of experience in member services, healthcare, a health plan, a call center, a medical office, care coordination, or a managed-care environment is preferred. An associate degree may substitute for one year of general customer service experience. Knowledge of Medicare Advantage Prescription Drug plans is highly preferred. Experience with Microsoft Word, Excel, PowerPoint, and Outlook is required. Ability to explain detailed information in clear, member-friendly language and communicate effectively in writing and verbally. Ability to de-escalate dissatisfied members and work toward resolution of complaints, grievances, and service issues within the position's authority. Ability to organize and prioritize work, manage follow-up items, meet deadlines, and maintain accurate documentation. Strong attention to detail, sound judgment, reliability, and the ability to work independently and as part of a team.

Compensation:

This is an hourly position with the pay range of $23.00 - $25.00 per hour which depends on several variables that are unique to each candidate, including, but not limited to, job-related skills, experience, relevant education, training, licenses/certifications, etc.

Benefits:

401k with company match! Health, Dental, and Vision insurances Generous Paid Time Off (PTO) 8 Paid Holidays per year 5 Paid Sick Days per year

Pay:

$23.00 - $25.00 per hour

Benefits:

401(k) 401(k) matching Dental insurance Health insurance Vision insurance

Education:

High school or equivalent (Required)

Experience:

Member Services:

2 years (Preferred) Call center: 2 years (Preferred)

Language:

English (Required) Mandarin (Preferred) Chinese (Preferred) Ability to

Commute:

Ontario, CA 91762 (Required)

Work Location:

Hybrid remote in Ontario, CA 91762