Health Plan Representative (Bilingual Spanish)

Job Description

Position(s) located within the local area Member Services Department reporting to Member Services Operations Director. Educates providers, staff and members on Health Plan benefits and services. Responsible for intake and resolution of complaint and grievance cases within the Medical Center and medical offices. Responsible for partnering with internal and external staff and departments to provide creative, timely solutions for member concerns. Assist in development of new programs / service improvements for members, providers and facility personnel. Assists with training, audits and other activities as necessary. This position helps drive the mission and business results for Kaiser Permanente.

Essential Responsibilities:

  • Act as liaison between the patient/member and Kaiser Permanente in providing general assistance and education on how to utilize multiple Kaiser system, resolve member complaints and grievances as efficiently as possible, and answer Health-Plan related questions.
  • Partner with other departments in the organization, such as Marketing and Health Education, and attends community, employer and KP events to ensure accurate information is provided to various clientele regarding KP services, benefits, and protocols.
  • Research, resolve and communicate Health Plan/coverage/benefit-related issues for members.
  • Maintain current comprehensive knowledge of Health Plan benefits, eligibility and exclusions.
  • Educate providers, staff and individual members on Health Plan benefits and services, explaining the details of specific member plans.
  • Participate in research or resolution of the organizations complaint and grievance process.
  • Responsible for communicationg with members or their authorized representatives(s), regarding the Health Plans communicationa dn grievance/complaint process.
  • Appropriately interview member/patient (or authorized representative of patient) in person or via phone regarding benefit, service, and medical care issues, document, and triage all case information to correspondence center. Accountable for investigation of issues, including collection and documentation of appropriate data.
  • Effectively handle and attempt to resolve member issues that are received from numerous sources.
  • Appropriately transfer all applicable cases and accompanying documentation after initial resolution effort in keeping with all regulatory requirements and internal policies and procedures.
  • Assist non-English or limited-English speaking customers in the use of interpreter services.
  • Responsible for communicating with members or their authorized representative(s), regarding the Health Plans response and grievance/ complaint process.
  • Ensure that complaints and grievances are processed in accordance with regulations, compliance standards, policies and procedures. Regulators include, but are not limited to: Center for Medicare/Medicaid (CMS), California Department of Managed Healthcare (DMHC), Department of Health Services (DHS), Department of Labor, Department of Consumer Affairs, the National Committee for Quality Assurance (NCQA).
  • Ensure integrity of departmental database by thorough, timely and accurate entry, consistent with regulatory protocols and applicable P&Ps and effectively manages case resolution inbox everyday.
  • Research and resolve, to the extent possible, member/system conflicts to obtain member satisfaction and minimize health plan risks.
  • Interpret and communicate Health Plan benefits/contracts to internal and external clients.
  • Responsible for the written and verbal interpretation of the Health Plan service agreement. Educate members/patients about their rights and responsibilities, medical center services, policies and procedures.
  • Identifies member – system conflict in an effort to prevent professional liability, minimize financial penalties to the organization, and retain satisfied members.
  • Communicate continually with a diverse set of internal and external clientele to achieve excellent results in the areas of complaint and grievance handling, compliance, documentation, benefit/contractual information, and enhancement of the member experience.
  • Collaborate with internal staff, managers and physicians, to identify opportunities to advocate for the member and resolve issues as quickly as possible.
  • Usiing conflict resolution and mediation skills, secure action from multiple stakeholders.

Grade 303

Basic Qualifications:


  • Minimum three (3) years of customer service experience in an environment where customer service, problem solving and compliance with regulatory requirements were the main components of the job.


  • High School Diploma or General Education Development (GED) required.

License, Certification, Registration

  • N/A

Additional Requirements:

  • Ability to handle a high volume of contact with customers.
  • MS Word required, tested at the intermediate level.
  • Ability to compose high quality, detailed written communications.
  • Ability to interview anxious and irate individuals and maintain a calm, but alert state of mind; ability to maintain composure under stress, and ability to empathize with individuals regardless of race, creed or economic status.
  • Ability to interview and investigate emotional situations with a level of sensitivity and understanding.
  • Ability to listen effectively and diffuse angry patients.
  • Ability to problem solve creatively, objectively and rapidly using good analytical skills.
  • Excellent interpersonal, verbal and written communication skills.
  • Ability to work with peers in self-managed teams and collaborate and coordinate with facilities throughout Northern California to access services for members.
  • Ability to prioritize work and ensure all compliance elements are met.
  • Ability to secure action from multiple stakeholders using conflict resolution and mediation skills.
  • Ability to use sound/professional judgment and to handle complex issues independently, but with the knowledge and ability to escalate and ask for help when needed.
  • Ability to multitask and manage time in order to perform well on long term projects while being flexible enough to assimilate short term projects on an ongoing basis within required timelines.
  • May need to travel within union jurisdiction to support operations.
  • Must be able to work in a Labor/Management Partnership environment.

Preferred Qualifications:

  • Bilingual skills preferred.
  • Strong understanding of health plan terminology preferred.
  • Bachelors degree preferred.


  • QBS Level I (language) Required