Job Description

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion.

Primary Purpose

Parkland Community Health Plan’s (PCHP’s) Member Advocate serves as a supporter for PCHP members in understanding, completion and submission of complaints and appeals. The Member Advocate is driven by thoughtful perseverance to improve the member experience with the Parkland Community Health Plan. Identifies trends and emerging issues and report and recommends solutions. Member Advocate immerses themselves in a rapidly evolving healthcare industry, while mastering skills in operational efficiency and external professionalism.

Minimum Specifications

Education

• High School diploma or equivalent.
• Bachelor’s degree is preferred.

Experience

• Five to seven years of experience working directly with health plan members and providers providing understanding and clarity to assure member satisfaction.
• Five years of experience working with Medicaid and CHIP programs.
• Thorough knowledge of member and provider appeals and complaints policies.
• Experience in research and analysis of claim processing is preferred.
• Experience in a supervisory role is preferred.

Equivalent Education and/or Experience

• May have an equivalent combination of education and experience to substitute for the experience requirements.

Skills or Special Abilities

• Bilingual in English and Spanish is required.
• Strong customer centric values with a patient, upbeat and a positive attitude.
• Outstanding interpersonal communication skills, both written and verbal.
• Maintain composure and compassion when juggling a high volume of tasks and deadlines.
• Ability to multi-task and use multiple computer applications at a time.
• Ability to form collaborative working relationships.
• Strong analytical skills focusing on accuracy and attention to detail.
• Knowledge of clinical terminology, regulatory and accreditation requirements is preferred.
• Proficient in Microsoft applications including Word, Excel, Outlook.
• Experience with QNXT is highly preferred.
• Ability to travel up to 10% of the time.

Responsibilities

• Serves as the lead facilitator and resource for departmental staff, third party administrators, state agencies and vendors, as needed.
• Serves as the senior contact in the absence of the Manager.
• Responsible for quality reviews of complaints and appeals. Provides feedback and training to staff to meet state metrics.
• Receives and documents member and provider complaints and appeals and provides the ongoing communication for a resolution.
• Collaborates across the health plan departments to find strategic solutions to member pain points.
• Investigates and resolves access and cultural sensitivity issues identified by Member Services staff, State staff, providers, advocacy organizations and recipients.
• Participates in ongoing training to remain up to date with local, state, and federal regulations and revise training materials as appropriate.
• Serves as a technical resource to colleagues regarding complaints, appeals, and similar situations requiring a higher level of expertise.
• Leads all committee meetings for complaints and appeals. Prepares agendas and reports to review complaint and appeals and trends.
• Reviews and coordinates with other teams to resolve incoming state complaints and inquires.
• Collaborates with leaders to assure policies and procedures, desk reviews and letters are up to date and audits for continuous improvement opportunities.

Job Accountabilities

1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws, and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.