General Overview: This role will support our members in the state of Delaware and will require up to 50% travel across the membership footprint. 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 Job Functions: Access to Quality Care 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. 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. 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. 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. 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). 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. Community Resources Complete outreach campaigns to members as assigned and document results. Strong organizational skills, including effective verbal and written communications skills Explore our hiring process « T S 29 - « T S 31 4 21 30 2
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