Member Advocate

We are searching for a Member Advocate someone who works well in a fast-paced setting. Investigates resolves and facilitates resolution of simple to moderately complex issues and questions reported by Texas Childrens Health Plan (TCHP) members prospective members healthcare providers or other entities relating to TCHP Managed Care Organization. Acts as the first point of contact for assistance or information regarding eligibility benefits authorizations claims referrals and/or any other Member/Provider needs. Assists and advocates for members and providers throughout the complaint and appeal process.

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Job Duties & Responsibilities

• Educates members about their rights and responsibilities which includes the complaints and appeals process
• Advocates for members during complaints appeals and fear hearings; complies with all necessary information to ensure appropriate Member representation
• Solves problems proactively and provides timely resolution to complex issues. Identifies the most appropriate course of action for problem resolution and effectively communicates the plans to those impacted. These issues frequently require research collaboration with other departments communications with external resources and response creation
• Responds to internal system trouble notifications and if necessary coordinates the involvement of other departments to facilitate problem resolution
• Serves as a continual resource for team member questions concerns etc.; viewed as being a primary available and approachable resource to team members
• Evaluates monitors and coordinates community resources
• Coordinates with DARS and local resources for the identification and support of employment and training opportunities for members
• Identifies options and initiates 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
• Evaluates monitors and coordinates community resources and maintains current knowledge of local and state resources
• Coordinates with DARS and local resources for the identification and support of employment and training opportunities for members
• Identifies options and initiates 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 need
• Assists manager in identifying opportunities for process and service improvement initiatives. Participates in the development and implementation of action plans

Skills & Requirements

• H.S. Diploma or GED
• 2 years experience customer service experience within managed care or insurance industry