Member Experience Advocate

Member Experience Advocate

How You'll Make a Difference

The Member Experience Advocate will assist the Manager of Member Experience with all work related to Common Ground Healthcare Cooperative's journey to world class member experience, which includes, but is not limited to:

• Acting as a member advocate to manage the complaints, grievances, appeals, and inquiries processes with compassion and empathy, and in accordance with all regulatory guidelines, including:
  • Intake, triage, and prioritization of cases
  • Documentation
  • Investigation/information gathering
  • Presentation to Appeals & Grievances Committee
  • Resolution correspondence
  • Reporting
  • Documentation, monitoring, and regulatory reporting obligations
• Continually looking for ways to improve the complaints, grievances, appeals, and inquiries processes using a member-focused approach to improve our overall level of service
• Supporting overall quality improvement programs and business standards
• Proactively mining our internal data and member feedback sources to identify pain points and make recommendations to solve them
• Assisting in creating and distributing any reports related to our journey to world class experience
• Being an integral part of the Member Experience Committee
• Other duties as assigned

Utilize Your Skills By:

Complaints, Grievances, Appeals, and Inquiries

• Upon receipt of a grievance or appeal, or by the next business day, contact the member via telephone to gauge understanding of their concern, ask questions, and determine next steps.
• Update CGHC grievance and OCI complaint tracking databases and utilize the information within the databases to prepare all required data reporting.
• Ensure that complaints, grievances, appeals and inquiries received are handled professionally and expeditiously.
• Triage, analyze, research, resolve and respond to grievances, appeals and inquiries from Members and regulatory agencies applying critical thinking, independent judgment, and business acumen to make final determinations and provide comprehensive responses within regulatory timeframes and requirements.
• Provide resolutions and written responses that follow Federal and State legislation/regulations and comply with National Committee for Quality Assurance (NCQA) standards.
• Provide written correspondence, supporting documentation, and rationale that cite the appropriate internal rule, guideline, protocol, medical policy or Certificate of Coverage (COC) language, etc. to applicable parties.
• Prepare and provide case summaries to the attendees of the weekly Appeals and Grievances Committee meeting prior to the meetings, facilitate the meetings including presenting findings.
• Provide Common Ground Healthcare Cooperative's written position to OCI and Members within the regulatory timeframes for responses.
• Collaborate with Chief Medical Officer and Senior Leadership on complaints, grievances, and appeals resolution.
• Maintain thorough knowledge of policies, procedures, guidelines, regulations, timeframes, and/or processes as well as CGHC policies and procedures and benefits for all products.
• Lead the development and maintenance of CGHC complaint tracking, providing solutions to prevent recurring complaint themes.
• Provide a high level of member satisfaction while responding to member and other stakeholder inquiries in a courteous and professional manner.

Member Experience Support

• Mining various sources of member feedback to proactively identify and address member concerns before they become a grievance or appeal. Potential work may include, but is not limited to:
  • Complaints, Grievances, and Appeals
  • Member survey feedback analysis and reporting
  • Member call listening
  • Post call IVR survey reporting
  • Social media monitoring, feedback, and reporting
• Assisting in creating and distributing the quarterly Member Experience Key Performance Metrics reports and any other applicable data as part of our journey to world class experience.
• Being an integral part of the Member Experience Committee by providing subject matter expertise on our member feedback sources.
• Perform other duties as assigned.

What You'll Need to Bring:

• Bachelor's degree in related field preferred; high school graduate or equivalent required.
• 3-5 years of previous health insurance or related industry customer service experience required.
• Must display effective interpersonal skills while dealing with members, stakeholders, and coworkers.
• Exude high level of empathy and compassion in member interactions/communications.
• Strong organizational/project management skills and ability to manage multiple administrative functions simultaneously.
• Outstanding verbal and written communication skills.
• Aptitude for collaborating with and presenting to senior leadership and C-suite executives.
• Ability to apply critical thinking in resolving complaints, grievances, appeals, and inquiries and evaluating data to make effective recommendations for global problem solving.
• Ability to analyze trends and recommend improvements in policies, procedures, communications, and training to prevent future member or other stakeholder issues.
• Experience in presenting information in a clear and concise manner.
• Ability to build strong relationships with stakeholders to achieve results.
• Ability to work and problem solve independently as well as an integral part of a team required.
• Must use good judgment and have the ability to act decisively at the right time.
• Strive for high quality work in completing assignments.
• Ability to act professionally and remain calm in stressful situations required.
• Knowledge of or ability to learn HIPAA requirements.
• Ability to read, understand and apply complex procedures and concepts.
• Knowledge of and proven proficiency using personal computers including the use of Microsoft Office applications required.
• Ability to learn and use Enrollment and Billing, Claims, and Customer Service call software required.
• Ability to work flexible hours as needed required.

General Requirements:

• Ability to treat others with dignity, respect, and courtesy required.
• Ability to follow operating procedures and practices.
• Ability to maintain member, employee, and proprietary confidentiality required.
• Ability to communicate effectively in-person and in all forms of communication required.
• Ability to pay attention to detail required.
• Ability to be flexible and adapt to changing situations required.
• Ability to adhere to punctuality/attendance standards required.
• Ability to provide professional image as outlined in the professional casual dress policy required.

We've Got You Covered

CGHC offers a comprehensive benefit package and broad range of programs to meet the needs of our employees to help protect your health, wealth, and future.