Company :Highmark Wholecare
Job Description :
I. GENERAL OVERVIEW:
This job is responsible for serving as a liaison between the member, the Health Plan, and the provider for the Gateway Health Plan Medicaid and Medicare product. The position conducts telephonic support to assess member needs, provide appointment scheduling assistance, educate members of their rights and responsibilities, and conduct a series of questionnaires to obtains and provide benefit information. This position is also responsible for assisting members in navigating the grievance and appeals process and representing member interests internally and externally.
II. ESSENTIAL RESPONSIBILITIES:
1. Communicate effectively. This position displays effective communication skills while performing the following functions:
• With staff, providers and members to accomplish business and member needs
2. Initiate outreach efforts, primarily by telephone, related to targeted preventive health initiatives
• Perform member education functions on the importance of targeted preventive health services
• Recruit, holistically assess and enroll members into Disease Management Programs as appropriate
• Assess opportunity for Care Management intervention and make appropriate referral
• Contact members, providers and community agencies to coordinate access to preventive health services
• Tracks all member and provider contacts in the appropriate computer systems for the purposes of data collection and record keeping
3. Conducts provider and community trainings on EPSDT services and other special preventive health initiatives
4. Contribute to the development and preparation of educational materials for members and providers
5. Collaborates with human services providers such as Head Start Programs, WIC and homeless shelters; as well as state agencies such as CYS and Juvenile Probation in the identification and outreach to members in need of services.
6. Participate in the development of outreach programs that are effective, measurable and innovative, with a special emphasis on reaching at risk members.
7. Maintain community repository by validating existing information, adding/deleting resources.
8. Assumes leadership and responsibility for selected projects
9. Other duties as assigned or requested.
• High School Diploma or GED
• One (1) year experience in Community Outreach/Customer Service
• Bachelor’s degree
• Previous experience as a Member Advocate or experience with complaint and grievance processes.
• Knowledge of Gateway Health Medicaid and the Medicaid Assured benefit package
Knowledge, Skills and Abilities
• Must be proactive, self-directed, assertive and creative in problem solving and system planning
• Strong active listening skills with the ability to act sensitively toward diverse people and situations .Ability to successfully interact with external customers, peers, colleagues, and management team
• Demonstrate effective time management skills and demonstrate an ability to prioritize and handle multiple tasks simultaneously
• Must demonstrate sound judgment and discretion when approaching problems and making decisions
• This position must be able to utilize sound and flexible productive work habits to set priorities, organize work and utilize time effectively
• Must be aware of issues Gateway Health Plan members face related to healthcare including transportation, child care, lack of knowledge concerning Preventive Health, distrust of the system as well as other personal, social, financial barriers
• Must demonstrate patience and empathy when interacting with members and all internal/external customers
• This job requires the ability to work independently and as a team member
IV. SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees? No
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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