Job Description
We are looking for a
Member Advocate Nurse (RN) – Population Health - someone to investigate, resolve and facilitate resolution of simple to moderately complex issues and questions reported by Texas Children's Health Plan (TCHP) members, prospective members, healthcare providers, or other entities relating to TCHP Managed Care Organization. Acts as the first point of contact for assistance or information regarding eligibility, benefits, authorizations, claims, referrals and/or any other Member/Provider needs. Assists and advocates for members and providers throughout the complaint and appeal process. Assists members with timely appointment scheduling. Translates medical terms into straight forward language and educate families how to navigate the healthcare system.
Think you have what it takes?
- General knowledge of health plans operations, claim and eligibility systems claim processing, and health care benefits
- Knowledge of Texas Department of Insurance requirements for the handling of Member complains and appeals
- Knowledge of managed care, Medicaid, call center desktop support application’s, customer relations techniques and general computer literacy
Required Qualifications
- Bachelor’s degree in nursing, associate’s degree, or Associate’s Degree, or Diploma in Nursing
- 3 years nursing experience
- RN License by Texas Board of Nursing or Nurse License Compact
Preferred Qualifications
- CHS- Community Health Worker certification from Texas department of State Health Services
- Knowledge of medical terminology
- Benefits, claims processing or membership knowledge
Specific Duties
- Provides member support and advocacy.
- Educates members about their rights and responsibilities, which includes the complaints and appeals process.
- Advocates for members during complaints, appeals, and fear hearings; compiles all necessary information to ensure appropriate Member representation.
- Solves problems proactively and provides timely resolution to complex issues. Identifies the most appropriate course of action for problem resolution and effectively communicates the plans to those impacted. These issues frequently require research, collaboration with other departments, communications with external resources, and response creation.
- Handles difficult callers; provides timely assistance and intervention with problem calls. Addresses challenging customers and problems that require escalation outside the department.
- Monitors real-time queue and adherence reports to ensure service level and response time objectives are met; oversees real time escalation plans.
- Conducts group training sessions and the dissemination of information to team members.
- Collaborates with Claims, Eligibility, Provider Relations, Business Operations, and other Health Plan departments as needed to resolve member and/or provider issues. Utilizes concepts of reflection and motivational interviewing with the member and the entire family unit, through various modes of communication.
- Evaluate and initiate the Member Advocacy Process for Service Coordination Line Escalations.
- Acts as backup to monitor Service Coordination Line.
- Educates providers on network compliance and policies and procedures of the Texas Children’s Health Plan, managed care, and Medicaid. Assists internal and external Member Services and Case Managers by serving as a communication link and providing education on member issues and authorization process and status.
- Provides education to members about the TCHP network, access to physicians, specialists, and other providers, TCH IDS and community resources, and basic health information. Assists in creating a positive work environment that promotes productivity, mentoring, teamwork, and cooperation.
- Elicits and considers differing viewpoints when analyzing issues.
- Guidance on closing care gaps (e.g., No PCP, discussing switching from low quality PCPs to high quality PCPs, reminder for completion of health risk assessment, reminders for exams/tests due)
- Conduct a multi-disciplinary health and healthcare (both in the field and virtual) assessment of the assigned client incorporating all relevant aspects as defined by Texas Children’s Health Plan
- Uses nursing/clinical knowledge to assess, plan, implement, coordinate, monitor, and evaluate options and services with a primary goal of provide clinically appropriate healthcare advocacy and conflict resolution.
- Supports initial and ongoing system training.
- Evaluates, monitors, and coordinates community resources.
- Participates in quality initiatives.
"As part of our commitment to maintaining a safe and healthy workplace, all successful candidates will be required to undergo respiratory fit testing in compliance with occupational health and safety standards. "
About Us
Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.
To join our community of 14,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities.
Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
