Senior Member Advocate

Community First Health Plans; San Antonio (TX); On-site; USD 55,000 - 90,000; Full time

Job summary

University Health in Texas seeks a dedicated professional to assist and direct the activities of Member Advocates within the Member Services Resolution Unit. You will support STAR, STAR Kids, CHIP, Medicare Advantage, and Commercial members in navigating benefits, services, and appeals, including responses via written correspondence and secure email.

You will work with the Service Coordination and Care Management team, assist in training new hires on the Complaint and Appeal process, ensure

Qualifications

• Bachelor’s degree in business, health care or related field with at least two years’ experience in the managed care industry is required.
• Minimum of five years’ experience in the managed care industry and two years’ Member Advocacy work may be substituted for college education.
• Complaints and appeals resolution or quality improvement management experience is preferred.

Responsibilities

• Assist and direct the activities of Member Advocates and all staff within the Member Services Resolution Unit.
• Represent STAR, STAR Kids, CHIP, Medicare Advantage, and Commercial members in navigating benefits, services, complaint and appeal processes.
• Provide education and support to access care and services, including written correspondence and secure email.
• Assist in accessing non-covered services and participating in interdepartmental processes as needed.
• Ensure HIPAA compliance in all aspects of operations within Member Services.
• Assist in training new hires regarding the Complaint and Appeal process.

Skills

Customer service

Communication

HIPAA compliance

Education

Bachelor’s degree in business, health care or related field

Job description

POSITION SUMMARY/RESPONSIBILITIES:

Assist, and direct the activities of Member Advocates and all staff within the Member Services Resolution Unit who represent STAR, STAR Kids, CHIP, Medicare Advantage, and Commercial members in navigating benefits, services, complaint and complaint appeals processes and provide education and support to access care and services. Assist with responses to include communication via written correspondence and secure email, as needed. They may also assist the member in accessing non-covered services, such as those provided in other social service or community programs. Additionally, they may be called upon to participate in other interdepartmental processes, as needed. Ensures compliance with the Health Insurance Portability and Accountability Act (HIPAA) related policies in regard to all aspects of operations within Member Services. Work closely with the Service Coordination and Care Management team and facilitate mediation in cases of reported complaints regarding service coordination and care management. Provide information to the appeal panels, employer groups and/or regulatory agencies when appropriate. Assist in training new hires regarding the Complaint and Appeal process.

EDUCATION/EXPERIENCE

Bachelor’s degree in business, health care or related field with at least two years’ experience in the managed care industry is required. Minimum of five years’ experience in the managed care industry and two years’ Member Advocacy work may be substituted for college education. Complaints and appeals resolution or quality improvement management experience is preferred.