Highmark · 11 hours ago
Medicaid Member Advocate
Greater Richmond Region
Full-time
Onsite
Mid, Senior Level
$24.53/hr - $38.76/hr
5+ years expHighmark Inc. is dedicated to assisting Medicaid members with their health and social challenges. The Medicaid Member Advocate plays a crucial role in collaborating with various stakeholders to ensure members receive the necessary care and support, while also addressing their health-related social needs.
Health CareHealth InsuranceInsuranceWellness
Responsibilities
Work with members, providers and the member’s case manager/care coordinator as needed to assist the member in obtaining care, including scheduling appointments and advising, enrolling in and accessing benefits
Investigate and resolve access and cultural sensitivity issues identified by HHO staff, State staff, providers, advocate organizations or members
Recommend policy and procedural changes to HHO 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)
Conduct ongoing analysis of internal health plan system functions through meetings with health plan staff, to affect access to medical care and quality of medical care
Provide input to HHO management on how provider network changes will affect member access and quality/continuity of care and develop/coordinate plans to minimize any potential problems
Monitor and manage referrals to the Member Advocate team (phone, voice mail, web portal and department email)
Function as a primary contact for member advocacy groups, human services agencies and the State entities, and work with these groups to identify and correct member access barriers. Connect members with community-based organizations
Takes ownership of each customer contact to anticipate customer needs, resolve their issues and connect them with additional services as appropriate
Assist members and authorized representatives to obtain Personal Health Information (PHI) and medical records
Maintain full and complete records of all activities performed on behalf of a member
Assist with necessary resources for members for whom English is not their primary language or who communicate non-verbally
Escalate member issues up the chain of command to meet the health and safety needs of the member
Maintain a member advisory committee as required in the State’s Quality Management Strategy
Develop, plan and coordinate the health plan’s (MAC meetings; holding meetings at a regular cadence where the content meets member and health plan needs and DMMA requirements)
Develop and implement strategies to increase member attendance, participation and engagement in MAC meetings
Research, interpret and respond to inquiries from members concerning health plan benefits and services
Resolve customer inquiries in an accurate, organized, efficient, and expert manner
Collaborate with the Clinical Services and Quality department to coordinate the needs assessment and action plan for addressing the education needs of health plan members
Encourage all member population and community participation in the health plan’s Health Awareness Series (HAS)
Educate and assist members with various elements of Medicaid entitlements, benefit plan information and available services created to enhance the overall member experience with the health plan
Organize and provide training and educational materials for HHO staff and providers to enhance their understanding of the values and practices of all cultures with which the health plan interacts
Review and recommend all health plan informational materials to be distributed to Medicaid enrollees for the purpose of assessing clarity and accuracy
Participate in local community organizations to acquire knowledge and insight regarding the special health care needs of Members and update and revise educational materials as appropriate
Guide members through the health care continuum, making them stakeholders in their own health through the use of self-management tools
Educate the member regarding the availability and assist in accessing health and wellness programs and the various health promotion incentive programs offered by the health plan
Assist the member with the health plan’s Grievance and Appeals process
Attend all Appeals hearings to support the member as assigned
Collaborate with Appeals & Grievances, Clinical Services, and Provider Services to support and educate the member through the Appeals Hearing process
Monitor Grievances with Grievance personnel to look at trends or major areas of concern, report to leadership and participate in action planning accordingly
Assist in the development, implementation and sustainability of a successful service recovery program for members
Provide service recovery post critical incidents, for Quality of Care (QOC) and Quality of Service (QOS) concerns, appeals & grievances, and complaints
Assist with questions and guidance post UM denial determinations
Coordinate with schools, community agencies and State agencies providing services to members
Participate in local community organizations to acquire knowledge and insight regarding the special health care needs of members to share with all internal stakeholders for analysis, decision-making and action planning accordingly
Assist members with any barriers to care as a result of their health-related social needs
Complete outreach campaigns to members as assigned and document results
Facilitate referrals to Clinical Services Case Management department staff based on the results of member outreach campaigns
Collaborate with the Clinical Services and Quality department to assist members with obtaining services, appointments and resources to close their preventive health care gaps
Implement measures to improve the overall experience for the HHO all member population
Identifies patterns generated by external and internal action effecting customer satisfaction
Assist the Director of Member Experience in the development and implementation of action plans to address trends in members’ CAHPS survey responses
Facilitate, educate and increase member utilization of the member website and the member portal
Assist the health plan in the development, updating and promotion of use of the member website, member and provider portal, member handbook, and provider directory
Other duties as assigned or requested
Qualification
Required
Bachelor's Degree in Business, Communications, or related field
6 years of related and progressive experience in lieu of Bachelor's degree
5 years in Healthcare Customer Service, Provider Service OR Member Service, preferably working with and advocating for low-income populations
Strong customer service orientation
Strong organizational skills, including effective verbal and written communications skills
Demonstrated sensitivity to the needs of people with disabilities and cultural sensitivity and competency
Experience with computers, including knowledge of Microsoft Word, Outlook, and Excel
Protects the confidentiality of member information and adheres to company policies regarding privacy/ HIPAA
Preferred
Community Based Member Advocacy Groups
Tracking and Trending Member Experience Survey Data (CAHPS)
Bilingual Background (Spanish very preferred)
Member/Patient Advocacy Certification (within two years of employment)
Data entry and documentation within member records is strongly preferred
Company
Highmark
Highmark provides health insurance plans for individuals and businesses.
10001+ employees
Funding
Current Stage
Late StageTotal Funding
$27.3M2018-04-06Grant· $25M
2014-08-07Grant· $2.3M
Leadership Team
Deborah Rice-Johnson
CEO, Diversified Businesses at Highmark Inc. and Chief Growth Officer
Paul Sikora
CTO Provider Services
Recent News
2025-12-11
Company data provided by crunchbase