Senior Specialist, Member Engagement - Remote PST hours

Molina Healthcare; San Antonio (TX); Remote; USD 60,000 - 80,000; Full time

Job summary

A healthcare organization in San Antonio seeks a dedicated professional to advocate for members, resolve issues, and assist with grievance processes. The ideal candidate will have a Bachelor's in Social Work, 3-5 years of Medicaid experience, and strong investigative skills. This role ensures members understand their rights and receive proper care. Competitive hourly pay and benefits are offered.

Benefits

Competitive benefits and compensation package

Equal Opportunity Employer

Qualifications

• 3-5 years experience working with the Medicaid population in an HMO or MCO setting.
• Experience working with disabled, underserved, and disadvantaged populations.

Responsibilities

• Resolve member issues and complaints.
• Investigate access and cultural sensitivity issues.
• Assist with grievance processes.
• Provide guidance to members and staff.
• Participate in Quality Assurance and Improvement Committees.

Skills

Advocacy for members

Complaint resolution

Investigative skills

Cultural sensitivity

Education

Bachelor's Degree in Social Work or related field

Graduate Degree in Social Work or related field

Job description

Job Description

Job Summary

Responsible for continuous quality improvements regarding member engagement and member retention. Represents Member issues in areas involving member impact and engagement including: Appeals and Grievances, Member Problem Research and Resolution, and the development/maintenance of Member Materials.

Knowledge/Skills/Abilities

• Serves as an advocate for members to resolve issues and complaints. Works with enrollees and providers to facilitate the provision of Medicaid benefits and ensure enrollee's rights are upheld. Helps enrollees understand their rights and benefits in working through the system.

• Investigates and resolves access and cultural sensitivity issues identified by HMO staff, State staff, providers, advocate organizations, subcontractors and enrollees.

• Monitors all formal and informal grievances with Grievance personnel to identify trends or problem areas of access and care delivery. Assists enrollees in the grievance process at the HMO and State levels and monitors outcomes.

• Provides timely written responses to inquiries; prepares written analyses of advocacy issues; and assists with documentation preparation for appeals, fair hearings or other formal/informal dispute resolution process.

• Provides ongoing training and educational materials to HMO and relevant subcontractor employees and providers as needed.

• Works in collaboration with the Care Management department to help resolve member issues/concerns, ensure that trends are identified and solutions outlined.

• Provides information, guidance and assistance, over the phone or in person, to members with disabilities or BC+ who call for help related to their HMO participation. Analyzes internal HMO system functions that affect enrollee access to medical care and quality of care.

• Serves as a resource for Molina staff and members regarding community agencies, services and referrals for special needs, Medicaid in general, or other related needs.

• Participates in the Statewide Advocacy Program for Managed Care including working with the State External Advocate, Enrollment Specialist and Ombudsmen on issues of access to medical care, quality of care, enrollment and disenrollment.

• Participates in HMO internal Quality Assurance and Improvement Committees to ensure services to enrollees are provided in accordance with all State/HMO requirements..

Job Qualifications

Required Education

Bachelor's Degree in Social Work, Human Services or related field.

Required Experience

3-5 years experience working with the Medicaid population, preferably in an HMO or MCO setting, with experience in working with disabled, underserved and/or disadvantaged populations.

Preferred Education

Graduate Degree in Social Work, Human Services or related field.

Preferred Experience

5+ years

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

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Pay Range: $21.16 - $42.2 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.