JOB SUMMARY
This job is responsible for serving as a liaison between the member, the Health Plan, and the provider for Highmark. The position conducts telephonic support to assess member needs, provide appointment scheduling assistance, and educating members of their rights and responsibilities. This position is also responsible for assisting members in navigating the grievance and appeals process and representing member interests internally and externally.
ESSENTIAL RESPONSIBILITIES
Communicate effectively with staff, providers and members to accomplish business and member needs
Initiate outreach efforts, primarily by telephone, related to targeted preventive health initiatives:
Perform member education functions on the importance of targeted preventive health service
Recruit, holistically assess and enroll members into Disease Management Programs as appropriate
Assess opportunity for Care Management intervention and make appropriate referral
Contact members, providers and community agencies to coordinate access to preventive health services
Tracks all member and provider contacts in the appropriate computer systems for the purposes of data collection and record keeping
Conducts provider and community trainings on EPSDT services and other special preventive health initiatives
Contribute to the development and preparation of educational materials for members and providers
Collaborates with human services providers such as Head Start Programs, WIC and homeless shelters; as well as state agencies such as CYS and Juvenile Probation in the identification and outreach to members in need of services.
Participate in the development of outreach programs that are effective, measurable and innovative, with a special emphasis on reaching at risk members.
Maintain community repository by validating existing information, adding/deleting resources.
Assumes leadership and responsibility for selected projects
Other duties as assigned or requested.
EDUCATION
Required
High School / GED
Substitutions
None
Preferred
Bachelor's Degree
EXPERIENCE
Required
1 year in Community Outreach or Customer Service
Preferred
Familiarity as a Member Advocate or with complaint and grievance processes
Familiarity with Delaware Medicaid and the Medicaid LTSS benefit package
LICENSES or CERTIFICATIONS
Required
None
Preferred
None
SKILLS
Must be proactive, self-directed, assertive and creative in problem solving and system planning
Strong active listening skills with the ability to act sensitively toward diverse people and situations .Ability to successfully interact with external customers, peers, colleagues, and management team
Demonstrate effective time management skills and demonstrate an ability to prioritize and handle multiple tasks simultaneously
Must demonstrate sound judgment and discretion when approaching problems and making decisions
This position must be able to utilize sound and flexible productive work habits to set priorities, organize work and utilize time effectively
Must be aware of issues Gateway Health Plan members face related to healthcare including transportation, child care, lack of knowledge concerning Preventive Health, distrust of the system as well as other personal, social, financial barriers
Must demonstrate patience and empathy when interacting with members and all internal/external customers
This job requires the ability to work independently and as a team member
Language (Other than English):
None
Travel Requirement:
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-based
Teaches / trains others regularly
Occasionally
Travel regularly from the office to various work sites or from site-to-site
Rarely
Works primarily out-of-the office selling products/services (sales employees)
Never
Physical work site required
Yes
Lifting: up to 10 pounds
Constantly
Lifting: 10 to 25 pounds
Occasionally
Lifting: 25 to 50 pounds
Never
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf )
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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org
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