Specialist, Member Engagement

Job Description

Job Summary: Responsible for continuous quality improvements regarding member engagement and member retention. Represents Member issues in areas involving member impact and engagement including: Appeals and Grievances, Member Problem Research and Resolution, and the development/maintenance of Member Materials.

Knowledge/Skills/Abilities:

• Maintains confidential telephone line to provide direct assistance to Members and/or family members who are unable to resolve their issues or complaints individually. Serves as an advocate in working with providers, regulatory agencies, outside agencies, co-workers and other departments as appropriate. Conducts in person meetings with Members and/or family members as appropriate. Logs all cases in a database.
• Assists members in the complaint and appeal process. Determines the nature of the member's needs or problem; informs members of their rights in the complaints and appeals process; and advises/refers as appropriate for investigation and resolution.
• Conducts focus groups in service delivery area as needed to ensure member needs are being addressed.
• Educates members on covered services available to them, including preventive services.
• Participates in annual member complaints and appeals training with health plan, including the member advocate/engagement role.

Job Qualifications:

Required Education: High School diploma.

Required Experience: 2 years experience in customer service, consumer advocacy, and/or health care systems. Experience conducting intake, interviews, and/or research of consumer or provider issues. Basic understanding of managed healthcare systems and mental health issues.

Required License, Certification, Association: Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

Preferred Education: Associate's or Bachelor's Degree in Social Work, Human Services or related field.