Description
General Summary of Position
Resolves enrollee complaints, grievances, and is the primary District of Columbia (DC) patient advocate, performing all patient advocacy functions including 24 hours, 7 day per week on call ombudsman support. Interacts directly with enrollees, staff, physicians, and others on the phone and electronically to resolve issues, acts as a resource, and documents information. Assists with the collection of quality improvement information via telephone and electronically. Responsible for computer data input, tracking, trending, analysis, survey processing, outbound calls, and correspondence. We recruit, retain, and advance associates with diverse backgrounds, skills, and talents equitably at all levels.
Primary Duties and Responsibilities
Responsible for overseeing the District of Columbia enrollee services program.Provides information, responds to inquiries, assists Enrollees with locating services and maintaining eligibility in a timely fashion.Resolves Enrollee Grievances.Assists Enrollees in filing and pursuing Appeals involving a denial, termination or reduction of benefits and services and serves as the primary point of contact for the DHCF Ombudsman, including 24-hour, 7-day availability.Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.Required to attend and participate in the MSFC Enrollee Advisory Committee meeting as well as other committees as requested.Demonstrates behavior consistent with MedStar Health mission, vision, goals, objectives and patient care philosophy.Evaluates, investigates, and resolves complaints and grievances by obtaining background information and data. Effectively conducts interviews with the patients, family members or providers, and collaborates with appropriate department staff and clinical personnel when appropriate and assists the patient in coordinating care or services when requested or required.Processes reimbursement requests in the designated computer system per MFC policies and procedures including requests from the Department of Health Care finance (DHCF) and/or Maryland Department of Health (MDH). Serves as the primary Point of Contact (POC) for correspondence with the DHCF and/or MDH and works closely with the member, internal associates, clinical staff, vendors, and provider's office as needed.Works closely with the Department Manager to complete reports, to ensure adequate grievance/complaint coverage, and to maintain compliance.Processes telephone calls from providers, other department staff and patients in regards to complaints, compliments, grievance procedures, denials and appeals, benefit issues and system or process issues in a courteous and timely manner. Maintains current knowledge of the MedStar Family Choice Benefit Plan. Facilitates member understanding and utilization of the Benefit Plan.Works collaboratively with the Member Services Department, District and/or State to process/oversee complaints. Accurately documents all pertinent information / interactions regarding complaints for legal and statistical purposes in the computer system. Correctly categorizes inquiries / complaints and refers cases appropriately to other departments for follow up; i.e. provider issues, or quality of care issues. Tracks all inquiries or complaints to ensure that cases are resolved within State required timeframes.Prepares reports for quarterly and/or annual meetings (ex: QIC, DC and/or MD Grievances and Appeals Committee, Appraisals, Evaluations, etc.) related to grievances.Presenter for quarterly and/or annual meetings (ex: QIC, DC and/or MD Grievances and Appeals Committee, Appraisals, Evaluations, etc.) related to grievances.Analyze grievance data and translate data into charts and graphs to be shared with regulators/auditors and the plan.Lead training for new enrollee services associates.Serves a liaison to select delegated vendors related to grievances.Serves as the main point of contact, key personnel, and on-call liaison for the MCP to the DC Ombudsman's and/or MDH office.CUSTOM.PRIMARY.DUTIES.RESPONSIBILITIES.ADDENDUM
Minimum Qualifications
Education
- High School Diploma or GED required
- Associate's degree preferred
- One year of relevant education may be substituted for one year of required work experience.
Experience
- 5-7 years Customer service experience in a managed care or social service setting required
- Medical experience preferred
Knowledge, Skills, and Abilities
- Ability to type 40 words per minute.
- Proficient computer skills preferred.
- Bilingual in Spanish preferred.
- Written and verbal communication skills.
This position has a hiring range of $59,820 - $101,836
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