Receive alerts when this company posts new jobs.
Member Advocate (Member Advocacy and Appeals)
Exempt or Non-ExemptExempt
Manage, research and respond to member and provider appeals, grievances, complex complaints, and inquiries relating to all aspects of health plan coverage consistent with contract, regulatory and/or accreditation requirements.
- Bachelor's (BA) degree and three (3) years of related work experience: or an equivalent combination of education and work experience.
- Basic Microsoft Office skills (email such as Outlook, Word, Excel, Powerpoint)
- Effective verbal and written communication skills.
- Skills to analyze database information, trends and continuous improvement activities.
- Ability to work independently, managing multiple priorities simultaneously and under strict time constraints.
- Experience in handling complex situations requiring problem identification and resolution.
- Familiarity with interaction of internal policies, systems and documents similar to health plan operations
Duties and Responsibilities
- Conducts critical analysis of highly complex and sensitive member and provider appeals, grievances and inquiries. Applies valid internal policies and procedures, contractual provisions and regulatory requirements as part of resolution process. Secures information from internal and external resources to resolve issues. Functions as a liaison with providers, members and internal decision makers in representing HMSA objectives, goals and expectations for meeting contractual, regulatory and accreditation requirements. Negotiates/resolves sensitive issues with internal and external parties. Negotiates fees on behalf of members for noncovered or nonparticipating provider services in addition to soliciting claims and other related medical information from providers in order to resolve member inquiries. Takes all facts and research from internal and external resources and presents a full explanation of the member's or provider's position and concerns to management and decision makers. Triages cases to resolve them upon initial inquiry to best service the member as well as minimize the number of cases escalated to senior management and executives. Maintains tracking database information for caseload.
- Participates on various cross departmental committees and other internal meetings to identify, clarify, research and resolve inquiries and issues. Identify required changes to policies and procedures based on case resolutions, statutory or regulatory changes, or accreditation requirements. Propose changes to management based on identification and analysis. Analyzes and identifies issues that require multiple department efforts to resolve, then coordinates discussions and meetings to develop process to resolve those issues. Presents recommendations to internal committees and executive management, and assists with the implementation of resulting decisions for change improvement and ultimate resolution. Assists management team in responding to internal investigations, reviews and audits; regulatory inquiries; and accreditation related audits as appropriate. Assist internal customers with complex member/physician inquiries. Handles assigned cases requiring skills of this position
- Identify member problems, member education needs, or trends and report these to director, as well as recommend resolution. Takes a proactive role in digesting and communicating any new regulation, standard, business change, etc. affecting the member advocacy and/or grievance and appeals process. Assists in the coordination of changes among departments. Assists in determining internal and external impacts
- Periodically will be asked to review clinical appeals prepared for presentation to the Appeals Committee (AC) including quality check of prepared case files and final communications. Will periodically oversee logistic planning for AC and facilitate communications with AC members. Regularly attends scheduled Appeals preparation meetings to observe/provide input to during case discussion. Periodically requested to attend Appeals Committee meeting as resource to Committee
- Evaluates/monitors work performance of staff and reports progress, barriers, and solutions. Acts as mentor to team members in order to further develop their member advocacy skills
- Provides training for department and other departments on policies and procedures relating to regulatory and accreditation requirements; leads discussions and provides training on problem identification and resolution
- Other duties/functions- assists in special projects, and performs other duties as assigned