Specialist, Member Rights

3 weeks ago

Long Beach, United States Molina Healthcare Full time

Job Description

Job Summary

The Specialist, Member Rights serves as a member advocate within the agency. This position ensures that members are informed of their rights and supports members through mediation and problem solving with interdisciplinary teams (IDTs). Maintains and manages an accessible appeals and grievance system for members to utilize.

Essential Job Functions

Provide support for members in understanding their rights and responsibilities related to programs in which they are enrolled, including due process procedures available to them in a grievance or appeal and other opportunities that may be available to express opinions and concerns.

Assist members to identify all rights to which they are entitled. If multiple grievances, review, or fair hearing processes are available to the member, the Member Rights Specialist will also offer advice about which process might best meet the member’s needs.

Assist individual members with issues and concerns that relate to care management, or the services provided by the organization.

Evaluate current practices to ensure the organization is compliant in regard to the ability to provide all members with the benefits we are contracted to coordinate. Ensure members receive notification according to contracted guidelines of timeliness and content.

Recognize, address, and escalate concerns when a member’s risk to health or safety is identified.

Conduct outreach and relationship building with outside agencies, including timely follow-up, maintaining neutral communications while facilitating conversations between different groups with opposing viewpoints, professionally representing the organization when interacting with outside groups (Advocacy agencies, Member Rights Forum, State of Wisconsin, Division of Hearings and Appeals, Metastar).

Collaborate with members, their supports, Interdisciplinary Teams (IDTs), and other departments within the organization in an attempt to resolve concerns and issues informally.

Collaborate with the organization’s training department to develop and administer IDT training related to member rights, adverse benefit determinations, personal use of resources counseling, and other related trainings as needed.

Assist in development of policies and procedures to ensure member rights are handled and understood uniformly and precisely. Work with interdepartmental stakeholders to find workable solutions.

Coordinate local appeals, grievances, and State Fair Hearings. This includes member/care team/State correspondence, explaining and distributing forms, scheduling, and attendance at appeal proceedings, leading local appeal committee meetings.

Recruit and train members of the plan’s Local Appeal and Grievance Committee.

**Grievance and Appeals Training**: Develop and implement training and education for staff, IDTs, Grievance Committee, and community about grievance and appeals procedures and preparation. Identify deficiencies in the tools available to Teams, and gaps in Team’s knowledge to address grievance/appeal trends.

Represent the Member Rights department through external audits, including gathering and preparation of audit responses.

Job Qualifications

**Required Education**:
BS/BA degree from an accredited college or university preferably in social services, nursing, or related field

**Required Experience, Knowledge, Skills, and Abilities**:
Knowledge and understanding of MCO and HMO funding sources, regulations, and guidelines.

Knowledge and understanding of long-term care services provided to older adults and persons with developmental and physical disabilities.

Knowledge and experience of case documentation and program monitoring audits

Microsoft Outlook, Excel, Word proficiency. Ability to navigate databases and computer literacy.

Experience in developing and conducting training. Ability to analyze, research and summarize information.

Ability to make recommendations to improve quality of case management and set standards of improvement.

Ability to organize complex materials and research state and federal guidelines.

Ability to present information in a concise and clear manner to a diverse workforce.

Exceptional and demonstrated written and verbal communications, presentation, and interpersonal skills.

Ability to work effectively with both others and independently.

Ability to lead and implement changes as required.

Ability to work with a diverse population.

Ability to handle fluctuating workload and prioritize departmental needs.

Able to make last-minute adjustments, handling fluctuating workload, merging concerns with Supervisory staff.

Ability to identify problems and trends and offer solutions while respecting other departmental functions.

Ability to maintain positive relationships with members, staff, and outside agencies.

**Required Licensure or Certification**:
**Preferred Qualifications**:
More than one year experience in a managed long-term care program.

2-5 years’ experience

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