Responsible for continuous quality improvements regarding member engagement and member retention. Represents Member issues in areas involving member impact and engagement including: Appeals and Grievances, Member Problem Research and Resolution, and the development/maintenance of Member Materials.
• Serves as an advocate for members to resolve issues and complaints. Works with enrollees and providers to facilitate the provision of Medicaid benefits and ensure enrollee’s rights are upheld. Helps enrollees understand their rights and benefits in working through the system.
• Investigates and resolves access and cultural sensitivity issues identified by HMO staff, State staff, providers, advocate organizations, subcontractors and enrollees.
• Monitors all formal and informal grievances with Grievance personnel to identify trends or problem areas of access and care delivery. Assists enrollees in the grievance process at the HMO and State levels and monitors outcomes.
• Provides timely written responses to inquiries; prepares written analyses of advocacy issues; and assists with documentation preparation for appeals, fair hearings or other formal/informal dispute resolution process.
• Provides ongoing training and educational materials to HMO and relevant subcontractor employees and providers as needed.
• Works in collaboration with the Care Management department to help resolve member issues/concerns, ensure that trends are identified and solutions outlined.
• Provides information, guidance and assistance, over the phone or in person, to members with disabilities or BC+ who call for help related to their HMO participation. Analyzes internal HMO system functions that affect enrollee access to medical care and quality of care.
• Serves as a resource for Molina staff and members regarding community agencies, services and referrals for special needs, Medicaid in general, or other related needs.
• Participates in the Statewide Advocacy Program for Managed Care including working with the State External Advocate, Enrollment Specialist and Ombudsmen on issues of access to medical care, quality of care, enrollment and disenrollment.
• Participates in HMO internal Quality Assurance and Improvement Committees to ensure services to enrollees are provided in accordance with all State/HMO requirements..
Bachelor’s Degree in Social Work, Human Services or related field.
3-5 years experience working with the Medicaid population, preferably in an HMO or MCO setting, with experience in working with disabled, underserved and/or disadvantaged populations.
Graduate Degree in Social Work, Human Services or related field.
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.