CVS Health

Member Advocate

Posted 11 days ago

Job Description

Job Description
The position is dedicated to work with the health plans members and
providers to facilitate the provision of benefits. The Member Advocate is
responsible for making recommendations to the DPCI management team
regarding any changes needed to improve either the actual care provided
or the manner in which the care is delivered. The Member Advocate must be
in an organizational location, within DPCI, which provides the authority
needed to carry out these tasks. The person assign to this position must
have substantial at least two [2] years experience in health care,
preferable working with low-income populations, and have demonstrated
cultural sensitivity.
Fundamental Components &
Physical Requirements
Additional Information
(Fundamental Components)
Background Experience
Desired
Education and Certification
Requirements
Investigate and resolve access and cultural sensitivity issues identified by
the health plan staff, State staff, providers, advocate organizations, and
members
Monitor the health plans formal and informal grievances with the grievance
personnel to look at trends or major areas of concern; discuss these
reports with community advocates, if requested
Coordinate with schools, community agencies and State agencies providing
services to members
Recommend policy and procedural changes to the health plans
management including those needed to ensure/improve member access to
care and quality of care; changes can be recommended for both internal
administrative policies and provider requirements
Function as a primary contact for member advocacy groups; work with
these groups to identify and correct member access barriers
Participate in local community organizations to acquire knowledge and
insight regarding the special health care needs of members
Analyze systems functions through meetings with staff
Organize and provide training and educational materials for the health
plans staff and providers to enhance their understanding of the values and
practices of all cultures with which the health plan interact
Provide input to management on how provider changes will affect member
access and quality/continuity of care; develop/coordinate plans to minimize
any potential problems
Review all informing material to be distributed to members
Assist members and authorized representatives obtain medical records
Have a bilingual person who has a preference to Spanish immediately
available.

Required Qualifications
Cultural Competency training experience preferred
Claims processing experience helpful
CPT, ICD-9-CM, and HCPCS experience preferred.
Project management of special events experience required.
Minimum of 3 years managed care or community relations experience, and
at least one year experience managing appeal and grievances in that
setting.

Preferred Qualifications
Performs other related duties and special projects as assigned.
Maintains availability/willingness to travel to various locations as frequently
as necessary to meet business needs (if travel is required)
Maintains availability and willingness to work the schedule necessary to
meet business needs
Works in a manner that is not disruptive to peers, supervisors and/or
subordinates.
Effective interpersonal skills and ability to act as a team player.
Statistical analysis skills helpful.
Ability to pay attention to detail, work in a fast paced/evolving environment.
Capable of meeting deadlines on a consistent basis.
Effective organizational skills and ability to manage multiple tasks.
Proficiency with word processing, spreadsheet applications, database
management and graphics experience. Microsoft Office Suite preferred
Ability to successfully interact with members, medical professionals and
health plan and government representatives.
Effective telephone, oral and written communication skills. Bilingual
preferred.

Education
Cultural Competency training experience preferred
Claims processing experience helpful
CPT, ICD-9-CM, and HCPCS experience preferred.
Project management of special events experience required.
Minimum of 3 years managed care or community relations experience, and
at least one year experience managing appeal and grievances in that
setting.

Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.


We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.