Member Advocate - PCHP

Are you looking for a career that offers both purpose and the opportunity for growth? Parkland Community Health Plan (PCHP) is a proud member of the Parkland Health family. PCHP is a Medicaid Managed Care Organization servicing Texas Medicaid and CHIP in the Dallas Service Area. PCHP works to fulfill of our mission by empowering members to live healthier lives. By joining PCHP, you become part of a team focused on innovation, person-centered care, and fostering stronger communities. As we continue to expand our services, we offer opportunities for you to grow in your career while making a meaningful impact. Join us and work alongside a talented team where healthcare is more than just a job-it's a passion to serve and improve lives every day.

Serves as a supporter for Parkland Community Health Plan (PCHP) members in understanding, completion, and submission of complaints and appeals. The Member Advocate immerses themselves in a rapidly evolving healthcare industry and improves the experience for members.

Minimum Specifications

Education

* High School diploma or GED is required.

* Bachelor's degree is preferred.

Experience

* Five years of experience working directly with health plan members and providers providing understanding and clarity to assure member satisfaction.

* Five years of experience working with Medicaid and CHIP programs.

* Highly knowledgeable of member and provider appeals and complaints policies.

Certification/Registration/Licensure

* Community Health Worker (CHW) preferred.

* Bilingual in English and Spanish is required.

* Ability to travel up to 10% of the time.

* Ability to multi-task focusing on accuracy and attention to detail.

* Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines. Ability to communicate complex information in understandable terms.

* Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships across and beyond the organization.

* Excellent analytical and problem-solving skills.

* Strong time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities.

* Ability to write clearly and succinctly with a high level of attention to detail.

* Proficient computer and Microsoft Office skills. Ability to learn new software programs and use multiple computer applications at a time. Experience with QNXT is highly preferred.

* Knowledge of Texas Medicaid, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual.

Responsibilities

Member Advocacy

* Serves as the facilitator and resource for members, providers, and departmental staff, third party administrators, state agencies and vendors, as needed.

* Responsible for quality reviews of member complaints and provides feedback to management staff.

* Collaborates across the health plan departments to find strategic solutions to member pain points, including updating/creating internal processes.

* Investigates and resolves access and cultural sensitivity issues identified.

* Receives inbound calls and conducts outbound calls to assist members with navigating the health plan and provide community resources as needed or requested.

* Serves as a technical resource to colleagues regarding complaints, and similar situations requiring a higher level of expertise.

* Collaborates with leaders to assure policies and procedures, desk reviews and letters are up to date and audits for continuous improvement opportunities.

* Attends quarterly Member Advisory Committee meetings and community events to provide and offer assistance to members in real time.

* Maintains PCHP Member Relations Onvida queue to resolve incoming member inquiries from call center.

* Responsible for documenting and tracking all Member Advocate interactions in SharePoint hub.

* Identifies trends and emerging issues and report and recommends solutions.

Quality

* Integrate health literacy principles into all communication including Members and Providers.

* Support strategies that meet clinical, quality and network improvement goals.

* Promote the use of Health Information Technology to support and monitor the effectiveness of health and social interventions and make data-driven recommendations as needed.

* For staff in clinical roles, foster collaborative relationships with members and/or providers to promote and support evidence-based practices and care coordination.

Regulatory

* Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements.

* Follows NCQA standards and member experience policies and guidelines.

Professional Accountability

* Promotes and supports a culturally welcoming and inclusive work environment.

* Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values.

* Adheres to organizational policies, procedures, and guidelines.

* Completes assigned training, self-appraisal, and annual health requirements timely.

* Adheres to hybrid work schedule requirements.

* Attends required meetings and town halls.

* Recognizes and communicates ethical and legal concerns through the established channels of communication.

* Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information.

* Maintains confidentiality at all times.

* Performs other work and participates in special projects as requested that is reasonably related to the employee's position, qualifications, and competencies.

Job Accountabilities

1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.

2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.

3. Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.

Parkland Community Health Plan (PCHP) prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.