Job Description

Your Role

Remote Position (disclaimer: remote status is subject to change upon company discretion at any time). Our Medi-Cal Customer Experience Teams receive incoming telephone calls from our members who need help navigating their Blue Shield of California Medi-Cal Insurance Coverage. If hired, you will be required to attend and complete a paid, mandatory virtual training. You must attend each day for 8 hours, totaling 40 hours per week for the required training period.

The following job summary will help you understand the candidates/people well suited to our Medi-Cal Call Center Team.

Job Summary:

Start Date August 4th 2025

Remote Position (disclaimer: remote status is subject to change upon company discretion at any time)

Our Medi-Cal Customer Experience Teams receive incoming telephone calls from our members who need help navigating their Blue Shield of California Medi-Cal Insurance Coverage.

As a Medi-Cal Correspondence Phone Support, Intermediate, you are in charge of upholding our mission of providing service worthy of our family and friends. Our members look to you to help them navigate healthcare, providing empathy and advocacy. You are empowered to provide members with peace of mind that their current issue is resolved and that none are on the horizon. Medicare provides health coverage to individuals 65 and older or those with a severe disability regardless of income, whereas Medi-Cal (California's state-run and funded Medicaid program) provides health coverage to those families with low income, as well as others who might be eligible for this program.

Successful CSRs deliver an effortless customer experience by:

Taking the lead - our CSRs take ownership of members' issues, relieving members' stress while guiding them to a quick and easy resolution.

Identifying future problems - not only do our CSRs solve the current member concern but they actively identify and solve any lurking complications the member may encounter after their first interaction.

Sharing insights with peers and management - our positive team culture relies on open communication to continuously improve how our work gets done.

Having fun! - our work is important, but we don't take ourselves too seriously. We love helping others and have a fun community dedicated to doing so!

You must also be:

Available to work a scheduled 8-hour shift, which includes 2 scheduled breaks and a lunch period, also available to work an occasional holiday as part of your regularly scheduled shift

Patient with members who call into our Centers with a question or a problem

A good listener and not only answer the questions they ask you, but identify and answer questions the member may not be aware they needed

Comfortable using a computer with 2 display monitors to allow you to navigate to multiple screens for information

Comfortable using Excel spreadsheets to calculate member premiums for health insurance

To multi-task using a computer; talking to the member, and entering member information into their online record

Responsibilities

Your Work

Responsibilities include:

Resolve incoming calls concerning member's eligibility, benefits, provider information, monthly premium billing, clinical and pharmacy needs

Compose routine and non-routine correspondence to answer benefits/provider inquiries in writing

Coordinate membership changes such as member's primary care physician

Perform routine to mid-level inventory reduction (i.e., member inquiries, may initiate claim adjustments, respond to emails, etc.)

Review and analyze member claims for accuracy as well as member education on how benefits are applied

Participate in quality and efficiency workgroups to continuously improve quality member/customer satisfaction as requested

Proactively analyze available programs, determine program eligibility and connect the Member to appropriate BSC vendors, Health Advocates, Social Workers, Pharmacy Techs, and Pharmacists. Verify the member is included in or targeted for any outreach or care gap programs and connect members to programs or services when appropriate. Engage members with their wellness plan options

Comprehensive resolution of pharmacy calls concerning benefits coverage, co-pays, formulary coverage, vacation overrides, and utilization management requirements

Provide prescription-related benefit coverage (e.g. explanation of coverage or benefit summary related): Provide prescription co-pays. Provide prescription formulary coverage information and utilization management requirements using web-posted printed formulary. Provide a brief description of coverage denial reasons and alternatives listed in the printed formulary. Perform prescription claim overrides

Provide deductible and max out of pocket information

Provide status of a prior authorization requests

Assist members may when and how to appeal a coverage decision

Other duties as assigned

Qualifications

Your Knowledge and Experience

Requires a High School Diploma or GED, or equivalent

Requires at least 3 years of prior relevant experience

Flexibility in availability is required including weekends and holidays, shifts are not guaranteed

Requires attending and completing training facilitated remotely

Requires basic job knowledge of Microsoft Suite systems and the ability to use applications on a computer proficiently

Requires high internet connectivity speed of a minimum 11MBPS and 3 MBPS upload speed

Requires private work location at their residence free from distractions and within 25 feet of their Wi-Fi modem

Preferred Qualifications

Bilingual - Spanish. Language proficiency as demonstrated by successful completion of an oral language proficiency test

Blue Shield of California

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(Medi-Cal) Customer Service Representative