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

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