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Reporting to the Chief Operating Officer, this position will support the Massachusetts Community Plan members for all existing and future products. The position includes both internal and external interfaces. The Member Advocate understands our members' needs and their health plan features including benefits and costs. The Member Advocate builds interactive, early problem detection elements within the existing support system, i.e. customer service, health services, community outreach and Sales. The Member Advocate is an active participant in the Plan's external appeals (Fair Hearing) processes, including coordinating materials, reviewing cases and preparing background information for hearings.
The Member Advocate becomes the member, family member or advocacy group representative within the plan. Member Advocate will utilize effective listening and verbal skills to understand the problem the member is experiencing and use sound judgment in resolving the issue quickly. This creates trust for the member and their family that the member will get the care they need and demonstrates that the member's care is a priority to our Health Plan.
The Member Advocate trends issues from internal and external sources clinical, network, quality, member advisory; through partnerships, develops resources and programs to support member and family and support plan goals (such as member transition to the community).
The Member Advocate will be the main contact for the Customer Call Center to escalate urgent issues to/for specific members and providers. Urgent member issues should be resolved within 24 hours and Provider issues resolved as soon as possible. Knowledge of the cross functional areas and staff is imperative for resolution of these issues. Developing good working relationships with the cross functional areas will assure that our member issues are resolved in a timely fashion.
Members with concerns are elevated to local Member Advocate if customer service (or, in certain instances, Appeals and Grievances) or health services are unable to completely satisfy Member. For example, some members have very serious health issues and require unique specialists for care. Their specialists are not in the network or have left the system. The Member Advocate will intervene to support the member's needs for appropriate care in the right setting.
The bi-lingual Member Advocate performs outreach functions to individual Members as s/he resolves those escalated issues. The Member Advocate also may hold or attend in-person meetings in the community with Providers and their staffs to assist with members getting needed services.
The Member Advocate facilitates member advisory group and uses feedback to develop process improvement strategies working with internal staff.
Positions in this function are responsible for first-level response and resolution of escalated issues with external and internal customers. Responsible for the overall delivery of benefits and services by providing support and guidance to existing and potential customers to ensure continued membership.
Primary Responsibilities:
- Analyzes and investigates.
- Provides explanations and interpretations within area of expertise.
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