/RESPONSIBILITIES: Supervise, assist, and direct the activities of Member Advocates and all staff within the Member Services Resolution Unit who represent STAR, STAR Kids, CHIP, Medicare Advantage, and Commercial members in navigating benefits, services, complaint and complaint appeals processes and provide education and support to access care and services. Assist with responses to include communication via written correspondence and secure email, as needed.
They may also assist the member in accessing non-covered services, such as those provided in other social service or community programs. Additionally, they may be called upon to participate in other interdepartmental processes, as needed. Ensures compliance with the Health Insurance Portability and Accountability Act (HIPAA) related policies in regard to all aspects of operations within Member Services.
Work closely with the Service Coordination and Care Management team and facilitate mediation in cases of reported complaints regarding service coordination and care management. Provide information to the appeal panels, employer groups and/or regulatory agencies when appropriate. Assist in training regarding the Complaint and Appeal process.
EDUCATION/EXPERIENCE Bachelor’s degree in business, health care or related field with at least two years’ experience in the managed care industry is required. Minimum of four years of supervisory work in health care administration, managed care, general health care industry may be substituted for college education. Complaints and appeals resolution or quality improvement management experience is preferred.