Medicaid Member Advocate

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JOB SUMMARY

The job is to assist Medicaid members with navigating a wide range of complex health and social challenges. With compassionate attention and excellent communication, the Member Advocate collaborates with HHO staff, members, providers, and community organizations to address the full continuum of members’ health care and health related social needs. The incumbent works alongside other internal departments including Member Services, Provider Services, and Clinical Services to provide an unsurpassed member experience.  Acts as a liaison for the member and community partners in a professional, self-directed manner to ensure and promote member satisfaction and retention. The incumbent is required by the State and acts as a point of contact to receive Medicaid member inquiries and fulfill all required responsibilities thoroughly, completely, and timely. Works with the all member population (and/or their representatives), families, caregivers, providers, and health plan staff to facilitate the provision of Medicaid benefits. Health plan members are referred to the Member Advocate(s) through, at a minimum, the following means: request from the State, the member’s case manager/care coordinator, resource coordinators, members, providers and the member services information lines.

ESSENTIAL RESPONSIBILITIES

• Access to Quality Care

  • Work with members, providers and the member’s case manager/care coordinator as needed to assist the member in obtaining care, including scheduling appointments and advising, enrolling in and accessing benefits.

  • Investigate and resolve access and cultural sensitivity issues identified by HHO staff, State staff, providers, advocate organizations or members.

  • Recommend policy and procedural changes to HHO management including those needed to ensure/improve member access to care and quality of care (changes can be recommended for both internal administrative policies and provider requirements).

  • Conduct ongoing analysis of internal health plan system functions through meetings with health plan staff, to affect access to medical care and quality of medical care.

  • Provide input to HHO management on how provider network changes will affect member access and quality/continuity of care and develop/coordinate plans to minimize any potential problems.

• Member Advocacy

  • Monitor and manage referrals to the Member Advocate team (phone, voice mail, web portal and department email).

  • Function as a primary contact for member advocacy groups, human services agencies and the State entities, and work with these groups to identify and correct member access barriers.
    Connect members with community-based organizations.

  • Takes ownership of each customer contact to anticipate customer needs, resolve their issues and connect them with additional services as appropriate.

  • Assist members and authorized representatives to obtain Personal Health Information (PHI) and medical records.

  • Maintain full and complete records of all activities performed on behalf of a member.

  • Assist with necessary resources for members for whom English is not their primary language or who communicate non-verbally.

  • Escalate member issues up the chain of command to meet the health and safety needs of the member.

• Member Advisory Council (MAC) Meetings

  • Maintain a member advisory committee as required in the State’s Quality Management Strategy.

  • Develop, plan and coordinate the health plan’s (MAC meetings; holding meetings at a regular cadence where the content meets member and health plan needs and DMMA requirements).

  • Develop and implement strategies to increase member attendance, participation and engagement in MAC meetings.

• Member Inquiries

  • Research, interpret and respond to inquiries from members concerning health plan benefits and services.

  • Resolve customer inquiries in an accurate, organized, efficient, and expert manner.

• Member Education

  • Collaborate with the Clinical Services and Quality department to coordinate the needs assessment and action plan for addressing the education needs of health plan members.

  • Encourage all member population and community participation in the health plan’s Health Awareness Series (HAS).

  • Educate and assist members with various elements of Medicaid entitlements, benefit plan information and available services created to enhance the overall member experience with the health plan.

  • Organize and provide training and educational materials for HHO staff and providers to enhance their understanding of the values and practices of all cultures with which the health plan interacts.

  • Review and recommend all health plan informational materials to be distributed to Medicaid enrollees for the purpose of assessing clarity and accuracy.

  • Participate in local community organizations to acquire knowledge and insight regarding the special health care needs of Members and update and revise educational materials as appropriate.

  • Guide members through the health care continuum, making them stakeholders in their own health through the use of self-management tools. 

  • Educate the member regarding the availability and assist in accessing health and wellness programs and the various health promotion incentive programs offered by the health plan.

• Grievances and Appeals Process

  • Assist the member with the health plan’s Grievance and Appeals process.

  • Attend all Appeals hearings to support the member as assigned.

  • Collaborate with Appeals & Grievances, Clinical Services, and Provider Services to support and educate the member through the Appeals Hearing process.

  • Monitor Grievances with Grievance personnel to look at trends or major areas of concern, report to leadership and participate in action planning accordingly.

• Service Recovery

  • Assist in the development, implementation and sustainability of a successful service recovery program for members.

  • Provide service recovery post critical incidents, for Quality of Care (QOC) and Quality of Service (QOS) concerns, appeals & grievances, and complaints.

  • Assist with questions and guidance post UM denial determinations.

• Community Resources

  • Coordinate with schools, community agencies and State agencies providing services to members.

  • Participate in local community organizations to acquire knowledge and insight regarding the special health care needs of members to share with all internal stakeholders for analysis, decision-making and action planning accordingly.

• Health-related Social Needs

  • Assist members with any barriers to care as a result of their health-related social needs.

• Member Outreach

  • Complete outreach campaigns to members as assigned and document results.

  • Facilitate referrals to Clinical Services Case Management department staff based on the results of member outreach campaigns. 

  • Collaborate with the Clinical Services and Quality department to assist members with obtaining services, appointments and resources to close their preventive health care gaps.

• Member Experience/Satisfaction

  • Implement measures to improve the overall experience for the HHO all member population.

  • Identifies patterns generated by external and internal action effecting customer satisfaction.

  • Assist the Director of Member Experience in the development and implementation of action plans to address trends in members’ CAHPS survey responses.

  • Member Website and Member Portal.

  • Facilitate, educate and increase member utilization of the member website and the member portal. 

  • Assist the health plan in the development, updating and promotion of use of the member website, member and provider portal, member handbook, and provider directory.

• Other duties as assigned or requested.

EDUCATION

Required

• Bachelor's Degree in Business, Communications, or related field 

Substitutions

• 6 years of related and progressive experience in lieu of Bachelor's degree

Preferred

• None

EXPERIENCE

Required

• 5 years in Healthcare Customer Service, Provider Service OR Member Service, preferably working with and advocating for low-income populations

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Preferred

• Community Based Member Advocacy Groups

• Tracking and Trending Member Experience Survey Data (CAHPS)

• Bilingual Background (Spanish very preferred)

LICENSES OR CERTIFICATIONS

Required

• None

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Preferred

• Member/Patient Advocacy Certification (within two years of employment)

SKILLS

• Strong customer service orientation
• Strong organizational skills, including effective verbal and written communications skills
• Demonstrated sensitivity to the needs of people with disabilities and cultural sensitivity and competency
• Experience with computers, including knowledge of Microsoft Word, Outlook, and Excel 
• Data entry and documentation within member records is strongly preferred
• Protects the confidentiality of member information and adheres to company policies regarding privacy/ HIPAA

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Rarely

Travel regularly from the office to various work sites or from site-to-site

Occasionally

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

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 job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

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Pay Range Maximum:

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.  The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

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 any category protected by applicable federal, state, or local law.

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