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Description
Job Description
Job Title:
Member Advocate, Quality Management
Job ID:
11023
Location: Nashville, TN
Full/Part Time:
Full-Time
Regular/Temporary:
Regular
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Responsibilities
JOB SUMMARY:
Responsible for member retention by investigating and leading the resolution of member complaints. Serve as a liaison/mediator between member, the provider and Plan, Provide education to the member on Medicaid Managed Care and their benefits with AMERIGROUP, informing and ensuring that members are aware of their rights and responsibilities, the complaint process, and health education activities available in the community. Support member outreach activities.
PRIMARY RESPONSIBILITIES:
1. Investigate, resolve, and document member complaints in accordance with AMERIGROUP policies and State requirements.
2. Conduct out-of office / home visits with members to educate and advise on AMERIGROUP programs, policy, and benefits as appropriate.
3. Investigate and resolve issues regarding members with non-compliant, behavioral, and abusive conduct identified by providers. Work with law enforcement officials as appropriate.
4. Conduct member interviews to ensure that members are informed of their rights and responsibilities.
5. Assist with member education related to prevention, outreach and education programs.
6. Identify members to participate on Plan committees.
7. Assist member as needed, including locating a PCP, obtaining medical records, obtaining transportation, and completing required forms. Resolution and coordination in barriers to care needs.
8. Assist in the preparation for a Grievance Panel, assuring member participation and explaining the process to the member.
9. Review complaint reports for accuracy and completeness and ensure required reports meet timely filing requirements.
10. Participate on the weekly complaint review committee as appropriate.
11. Assist in the maintenance of the complaint database.
12. Prepare additional reports and presentations as needed to support community relations, Provider Services and member education activities.
13. Attend community events as appropriate.
14. Track, trend, and report quality and access complaints by provider. Coordinate with provider relations for follow-up of issues identified.
15. Act as member advocate with providers, CBO's, and AMERIGROUP associates as indicated.
16. Serve as liaison with state hot line staff and internal compliance personnel.
17. Work with other AMERIGROUP departments and with physicians to resolve member issues.
18. Establish and maintain working relationships with member advocacy groups.
19. Other duties as assigned.
EDUCATION AND EXPERIENCE:
Education
Required:
Two-year degree in a related field or. 3 5 years experience in a social or health related service-oriented industry
Years and Type of Experience Required:
Required:
3 5 years experience in a social or health related service-oriented industry
Experience with complaint/grievance processes
Preferred:
Previous experience in a Medicaid Managed Care Health Plan
Successful record of community volunteer work
Previous experience in outreach to members to include resolution of issues
Specific Technical Skills
Required:
Excellent interpersonal, organizational, problem solving, multitasking, analytical and communication skills
Excellent Customer Service skills
Appreciation of cultural diversity and sensitivity towards target population
Professional telephone etiquette.
Presentation skills
Ability to work calmly and effectively under adverse conditions
Computer keyboard and word processing proficiency
Preferred:
Bi-lingual preferred
Strong mediation skills
Certifications or Licensure
Required:
Must possess a valid driver's license and required insurance
Preferred:
Other
Required:
Ability to work evenings and weekends as needed
Preferred:
Established working relationships with Community Based Organizations
SCOPE INFORMATION
# Direct Reports
# Indirect Reports
Budgetary $ Responsibility
PHYSICAL REQUIREMENTS
Must be able to operate a computer
Must be able to operate a telephone
Local travel required - must be able to travel locally to physician offices and members homes
Must be able to communicate verbally
Must be able to tolerate standing and sitting for long periods of time
Must be able to operate a motor vehicle
Equal Employment Opportunity
In accordance with state and federal laws, employment offers are tendered solely on the basis of qualifications without regard to race, religion, color, national origin, age, sex, marital status, sexual orientation, handicap (including disabled veterans) or Vietnam Era veteran status.
AMERIGROUP administers pre-employment drug testing as a condition of employment and a satisfactory criminal history background report.
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Details:
Job Id:
731407A1
Posted / Updated:
3/27/2010 3:54:20 AM
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