Internal Ombudsman Jobs (NOW HIRING)

When you become a member of Team DHCF (Department of Health Care Finance), the state Medicaid agency for the District of Columbia, you join our "Mission Possible!" We work every day, in concert with various District government agencies, to streamline access to comprehensive, affordable, and quality healthcare services for District residents. Whatever your position within our agency, you will positively impact beneficiaries, their families, and their future! We invite you to bring your skills, your experience, and your passion to a job that makes a difference.
Job Summary
The primary purpose of this position is to serve as a healthcare advocate and apply professional nursing clinical knowledge, experience, and education to residents based on one or more areas of nursing practice, but does not provide direct patient care. The incumbent will assist the residents of the District to navigate the various medical intricacies that make up the health care system and educate them on the various health insurers that may meet their needs. The incumbent will use their professional clinical expertise to assist residents or enrollees that are members in a commercial health plan in the District of Columbia who are covered by the Health Care Bill of Rights and Health Care Ombudsman Program Establishment Acts.
Duties and Responsibilities
Organizes, leads, prepares, and presents clinically complex cases, analyzes written documents, discusses oral reports, and provides briefings on various healthcare administration topics. Conducts clinical research independently and provides clinical evidence-based research for internal and external consumer appeals. Serves as a liaison with health plans, healthcare providers, consumers, family members, and government agencies. Serves and/or co-leads the Health Care Advisory Ombudsman Clinical Subcommittee meetings. Educates and assists consumers with the external appeal process. Provides education instruction/training to consumer advocates and healthcare providers in the District. Presents consumers with information required to make informed health care and treatment decisions. Receives, prepares, and submits cases to the external review organizations. Collaborates with other healthcare professionals and service providers to ensure optimal healthcare is provided based on consumers' complaints or grievances.
Receives grievances, appeals, and complaints and responds within appropriate timeframes established by law. Maintains caseloads to bring resolution to complex cases of consumers and providers according to the nurse practice standards. Makes recommendations to the Ombudsman regarding necessary legislative or policy changes to the Health Care Bill of Rights and Health Care Ombudsman Program, and makes clinical recommendations as appropriate to physicians, other healthcare providers, insurance companies, and consumers to improve consumer healthcare outcomes. Engages in problem-solving techniques on policy issues related to clinical services and recommends solutions to the Ombudsman on policy matters and critical issues. Manages the tracking system for consumer provider complaints. Identifies barriers to resolve clinical issues and complaints/grievances and consults with the Ombudsman to work on ways to improve the process. Evaluates the quality and effectiveness of nursing standards related to the organizational system of the office. Stays abreast of current literature, communicates with colleagues, and participates in professional organizations or conferences for new development in nursing standards.
Qualifications and Education
Successful completion of a PhD or equivalent doctoral degree from a professional nursing educational program or related medical science field;
or
At least one full year of professional nursing experience at the next lower grade level and possession of a diploma, associate degree, bachelor's degree, or master's degree from a professional nursing educational program.
In addition, Specialized Experience Experience that equipped the applicant with the particular knowledge, skills, and abilities to successfully perform the duties of the position, and this is typically in or related to the work of the position to be filled. To be creditable, at least one (1) year of specialized experience must have been equivalent to at least the next lower grade level in the normal line of progression.
Licenses and Certifications
Must possess and maintain a valid District of Columbia Registered Nurse license.
Certification in Cardiopulmonary Resuscitation with Automated External Defibrillator Component (CPR/AED).
Working Conditions/ Environment
The work is performed in a typical office setting.
Other Significant Facts
Tour of Duty: Monday Friday; 8:15 a.m. 4:45 p.m.
Pay Plan, Series, and Grade: CS-0610-12
Promotion Potential: No known promotion potential
Collective Bargaining Unit (Union): This position is represented by a collective bargaining unit and is subject to union dues thru payroll deduction.
Residency Requirement: Applicants claiming Residency Preference will be required to maintain residency in the District of Columbia for a minimum of seven (7) years. Failure to do so may result in forfeiture of employment.
Position Designation: This position has been designated as security sensitive; therefore, the incumbent of this position will be subject to enhanced suitability screening pursuant to Chapter 4 of DC Personnel Regulations, Suitability, and as such, incumbents of this position shall be subject to criminal background checks, background investigations, and mandatory drug and alcohol testing, as applicable.
EEO Statement: The District of Columbia Government does not discriminate or retaliate in employment on the basis of race, color, religion, sex, pregnancy, gender identity and expression, national origin, family responsibilities, political affiliation, sexual orientation, marital status, homeless status, disability, genetic information, age, membership in an employee organization, participation in a legally protected activity, parental status, matriculation, personal appearance, credit information, status as a victim or family member of a victim of domestic violence, sexual offense, or stalking, military service, or other non-merit factor.