Healthcare Advocate

Job Description

Job Description

Position Summary

The Healthcare Advocate serves as a trusted resource for members navigating the healthcare system. This position helps individuals understand their healthcare options, resolve medical billing and insurance-related issues, identify appropriate and cost-effective healthcare services, and coordinate care when needed.

The Healthcare Advocate works directly with members, healthcare providers, hospitals, insurance carriers, laboratories, imaging facilities, and other healthcare organizations to help members make informed healthcare decisions while reducing confusion, unnecessary costs, and administrative burden.

The ideal candidate is compassionate, resourceful, detail-oriented, and comfortable advocating on behalf of individuals who may be dealing with complicated medical bills, insurance questions, or difficulty navigating the healthcare system.

Essential Duties and Responsibilities

Member Advocacy & Support

• Serve as a primary point of contact for members seeking assistance navigating the healthcare system.
• Listen to members' concerns and determine the appropriate advocacy services and next steps.
• Educate members regarding healthcare options, benefits, available resources, and potential costs.
• Assist members in understanding medical bills, Explanation of Benefits (EOBs), and other healthcare-related documents.
• Help members identify appropriate physicians, facilities, laboratories, imaging centers, pharmacies, and other healthcare providers.
• Assist members with locating high-quality, cost-effective healthcare services.
• Provide ongoing communication and follow-up until the member's issue has been addressed or resolved.

Medical Bill Advocacy

• Review medical bills for potential errors, duplicate charges, billing discrepancies, or other issues requiring additional investigation.
• Contact healthcare providers and facilities to obtain clarification regarding charges.
• Assist members in understanding their financial responsibility for healthcare services.
• Work with providers, facilities, and other parties to resolve billing disputes when appropriate.
• Assist with medical bill negotiation and payment arrangements in accordance with company policies.
• Document savings and financial outcomes resulting from advocacy efforts.

Insurance & Benefits Assistance

• Help members understand insurance benefits, deductibles, copayments, coinsurance, network requirements, and other plan provisions.
• Assist members with questions regarding denied or incorrectly processed claims.
• Communicate with insurance carriers and healthcare providers to research claim or billing issues.
• Assist members with appeals or other administrative processes when appropriate.
• Help members understand the differences between insurance-covered services and available cash-pay options.

Care Navigation

• Research healthcare providers and facilities based on member needs, geographic location, availability, quality, and cost.
• Assist members with coordinating appointments and healthcare services when appropriate.
• Identify lower-cost alternatives for laboratory testing, imaging, prescriptions, procedures, and other healthcare services.
• Help members navigate referrals and other administrative requirements.
• Follow up with members after services to ensure their needs have been addressed.

Provider & Facility Communication

• Communicate professionally with physician offices, hospitals, laboratories, imaging centers, pharmacies, insurance carriers, and other healthcare organizations.
• Obtain pricing and billing information when permitted.
• Coordinate with providers and facilities to resolve member concerns.
• Develop productive working relationships with healthcare organizations and vendors.

Documentation & Case Management

• Maintain accurate and detailed documentation of all member interactions and advocacy activities.
• Document telephone calls, correspondence, provider communications, financial information, case status, and outcomes.
• Maintain appropriate case notes and follow-up schedules.
• Track cases through completion and ensure outstanding issues receive appropriate follow-up.
• Escalate complex or sensitive cases to management when appropriate.

Privacy & Confidentiality Responsibilities

• Protect the confidentiality of member information and medical information.
• Handle Protected Health Information (PHI) in accordance with applicable HIPAA requirements, company policies, and contractual obligations.
• Access member information only when necessary to perform assigned job responsibilities.
• Follow company privacy, security, confidentiality, and information-handling procedures.
• Immediately report suspected privacy or security incidents according to company policy.

Required Qualifications

• High school diploma or equivalent required; associate or bachelor's degree preferred.
• Prior experience in healthcare, medical billing, health insurance, patient advocacy, customer service, benefits administration, or a related field preferred.
• Strong verbal and written communication skills.
• Excellent customer service and interpersonal skills.
• Strong organizational and problem-solving abilities.
• Ability to research complicated healthcare and billing issues.
• Ability to communicate professionally with members, providers, insurance companies, and healthcare facilities.
• Strong attention to detail and ability to maintain accurate documentation.
• Ability to manage multiple cases and priorities simultaneously.
• Comfortable working with confidential and sensitive information.
• Proficiency with computers, CRM/case-management systems, email, and standard office applications.

Preferred Qualifications

Experience in one or more of the following areas is preferred:

• Healthcare advocacy
• Medical billing
• Medical bill negotiation
• Health insurance claims
• Healthcare benefits
• Hospital or physician-office administration
• Revenue cycle management
• Patient financial services
• Care navigation
• Pharmacy or prescription assistance
• Healthcare customer service

Knowledge of healthcare terminology, CPT/HCPCS codes, ICD-10 codes, EOBs, insurance networks, deductibles, coinsurance, and healthcare billing practices is beneficial.

Core Competencies

Compassion: Demonstrates patience, empathy, and professionalism when assisting members who may be experiencing stressful healthcare or financial situations.

Advocacy: Willing to ask questions, investigate issues, and pursue appropriate solutions on behalf of members.

Problem Solving: Able to evaluate complicated healthcare situations and identify practical solutions.

Communication: Clearly explains healthcare and financial information in language members can understand.

Attention to Detail: Carefully reviews bills, claims, documents, and case information for accuracy.

Persistence: Willing to follow up with providers, insurance companies, and other organizations until issues are appropriately addressed.

Integrity: Handles confidential information responsibly and maintains professional and ethical standards.

Performance Expectations

Performance may be evaluated based on factors including:

• Member satisfaction
• Case resolution rate
• Accuracy and completeness of case documentation
• Response and follow-up times
• Medical bill savings or negotiated savings, where applicable
• Identification of lower-cost healthcare alternatives
• Quality of member communication
• Compliance with privacy and confidentiality requirements
• Ability to manage assigned caseload effectively

Physical & Work Requirements

This position primarily involves computer and telephone-based work. The employee must be able to communicate effectively by telephone, email, video conference, and other electronic communication methods and spend extended periods working at a computer.

Equal Employment Opportunity

[Company Name] is an equal opportunity employer and considers qualified applicants without regard to legally protected characteristics in accordance with applicable federal, state, and local laws.

Position Purpose

The goal of the Healthcare Advocate is simple: help members better understand the healthcare system, find appropriate and cost-effective care, resolve healthcare-related problems, and provide a knowledgeable advocate who represents the member's interests throughout the process.

Advantage PHC, Inc is a Healthcare Concierge and Advocacy Company helping everyday consumers navigate through the complex healthcare system.

Company Description

Advantage PHC, Inc is a Healthcare Concierge and Advocacy Company helping everyday consumers navigate through the complex healthcare system.