Member Advocate-Tyler,TX

About Texas Children's Hospital

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.   To join our community of 14,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.

Summary:

We are searching for a Member Advocate — someone who works well in a fast-paced setting. In this position, you will investigate, resolve and facilitate the resolution of simple to moderately complex issues and questions reported by Health Plan and prospective members, healthcare providers, or other entities relating to the Managed Care Organization. You will act as the first point of contact for assistance or information regarding eligibility, benefits, authorizations, claims, referrals, and/or any other member/provider needs. Lastly, you will assist and advocate for members and providers throughout the complaint and appeal process and assist with any appointment scheduling.

 

Think you’ve got what it takes?

Responsibilities :

• Educate members about their rights and responsibilities, which includes the complaints and appeals process
• Advocate for members during complaints, appeals, and fear hearings; comply with all necessary information to ensure appropriate member representation
• Respond to internal system trouble notifications and, if necessary, coordinate the involvement of other departments to facilitate problem resolution
• Serve as a continual resource for team member questions, concerns, etc.
• Identify options and initiate collaboration with referral sources to ensure member/family linkage to specialists, home care providers, financial assistance, housing, meals, transportation, and other community resources as appropriate for members with unmet needs
• Assist the manager in identifying opportunities for process and service improvement initiatives and participates in the development and implementation of action plans

Qualifications:

• • High school diploma or GED required
  • 2 years’ experience in customer service experience within managed care or insurance industry required
  • An Associate degree may substitute for 2 years of the required experience
  • CHW(Community Health Worker) certification preferred
  • Bilingual in English/Spanish Preferred

  Please note: As a worker with the Health Plan organization, a signed consent allows us to disclose an employee’s home address for the purposes of geomapping.

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