Member Rights Specialist

Lakeland Care Incorporated•Fond Du Lac, WI

About The Position

Join our award winning culture as we serve members in your area! Under the general direction of the Member Rights Manager (MRM), this position provides support to Lakeland Care, Inc. (LCI) members and their representatives in understanding and exercising their rights and responsibilities related to Family Care, including due process procedures available to them in a grievance or appeal. This position assures members, LCI employees, and providers are offered the necessary education and support regarding member rights and organizational compliance with process deadlines as well as upholding and prioritizing members’ rights. In addition, this position represents LCI through verbal and written communication for hearings, committees and meetings, while providing support and guidance to members, member representatives and teams to create a culture of shared values and member satisfaction. This position is required under the DHS Family Care contract and requires regular collaboration with external parties such as: ombudsman, attorneys, WI DHS oversight staff, and Quality oversight staff (Metastar). Essential Competencies: Facilitate grievance and appeal processes including but not limited to: assisting members with due process rights; coordinating and leading mediation, pre-hearing meetings and hearings; investigating case notes and review of new material; ensuring all parties have related documentation for each case; drafting and sending all appeal and grievance correspondence and maintaining all case documentation in an organized, confidential and secure manner. Monitor Lakeland’s contractual responsibilities specific to Members’ Use of Personal Resources (MUPR) including consultation and providing education to care teams, as well as ensuring documentation of all MUPR instances. Assist in reviewing data to identify trends and opportunities for improvement and successes. Participate in the annual external Quality review representing the Member Rights Specialist role. Consult with senior leaders as needed when applying policy and contract interpretations, ensuring timely communication and escalation of issues with potential risk and/or impact to member health and safety and/or operations. Gather information about member complaints, identify obstacles and strategies for conflict resolution and management. Actively participate in informal grievance/appeal resolution and member centered problem solving. Ensure availability of informal and formal resolution procedures of all appeals and grievances. Provide appropriate and timely follow-up, documentation, and mandatory reporting on all appeals, grievances, complaints, and concerns reported by members. Maintain a well-organized case load and accurate record of communications, interactions and collaborations. Assist with initial mediation to resolve member appeals and grievances through the following systems: LCI appeals, State Fair Hearing, Department of Health Services (DHS) reviews, and Lakeland local systems. Serve as a liaison between members and care team (and others in the organization when appropriate) to facilitate problem solving, mediation and conflict resolution. Assist Interdisciplinary Team (IDT) staff in providing support for members and their representatives in understanding their rights and responsibilities. Build and maintain strong relationships with external agencies including: Disability Rights Wisconsin, Board on Aging and Long-Term Care Ombudsman and WI Department of Health Services staff. Maintain Lakeland’s Appeal and Grievance hearing committee; recruit committee membership as needed and ensure proper training of committee members. Participate in variety of internal and external committees and workgroups as requested. Coordinate training related to appeals and grievances and member rights for all relevant stakeholders.

Requirements

Bachelor’s degree in Social Sciences, Health Care Administration, related discipline, or equivalent combination of education and experience (includes knowledge, skills, and abilities).
Must possess intermediate skills with Microsoft Office Suite, particularly Word, PowerPoint, Excel, and Outlook.
Must have one to two years of experience related to advocacy or negotiation. Effective problem solving and conflict resolution skills required. Experience with mediation, grievances and appeals preferred.
Awareness of and experience with the nature of physical disabilities, disabilities due to advanced age, and intellectual/developmental disabilities.
Knowledge of appropriate service for the treatment and care of persons with intellectual /developmental disabilities, physical disabilities, and frail elderly.
Knowledge of the Wisconsin Family Care Program, managed care principles, and Family Care contract.
Knowledge of Chapters 10, 51, 55, 880 procedures and requirements related to member rights.
Effective, high level written and oral communication skills.
Excellent organizational skills
Demonstrated commitment to providing excellent customer service required.
Valid driver’s license with reliable transportation, the ability to travel to all LCI service areas and acceptable driving record and proof of adequate insurance required.

Nice To Haves

Experience with mediation, grievances and appeals preferred.

Responsibilities

Facilitate grievance and appeal processes including but not limited to: assisting members with due process rights; coordinating and leading mediation, pre-hearing meetings and hearings; investigating case notes and review of new material; ensuring all parties have related documentation for each case; drafting and sending all appeal and grievance correspondence and maintaining all case documentation in an organized, confidential and secure manner.
Monitor Lakeland’s contractual responsibilities specific to Members’ Use of Personal Resources (MUPR) including consultation and providing education to care teams, as well as ensuring documentation of all MUPR instances.
Assist in reviewing data to identify trends and opportunities for improvement and successes.
Participate in the annual external Quality review representing the Member Rights Specialist role.
Consult with senior leaders as needed when applying policy and contract interpretations, ensuring timely communication and escalation of issues with potential risk and/or impact to member health and safety and/or operations.
Gather information about member complaints, identify obstacles and strategies for conflict resolution and management.
Actively participate in informal grievance/appeal resolution and member centered problem solving.
Ensure availability of informal and formal resolution procedures of all appeals and grievances.
Provide appropriate and timely follow-up, documentation, and mandatory reporting on all appeals, grievances, complaints, and concerns reported by members.
Maintain a well-organized case load and accurate record of communications, interactions and collaborations.
Assist with initial mediation to resolve member appeals and grievances through the following systems: LCI appeals, State Fair Hearing, Department of Health Services (DHS) reviews, and Lakeland local systems.
Serve as a liaison between members and care team (and others in the organization when appropriate) to facilitate problem solving, mediation and conflict resolution.
Assist Interdisciplinary Team (IDT) staff in providing support for members and their representatives in understanding their rights and responsibilities.
Build and maintain strong relationships with external agencies including: Disability Rights Wisconsin, Board on Aging and Long-Term Care Ombudsman and WI Department of Health Services staff.
Maintain Lakeland’s Appeal and Grievance hearing committee; recruit committee membership as needed and ensure proper training of committee members.
Participate in variety of internal and external committees and workgroups as requested.
Coordinate training related to appeals and grievances and member rights for all relevant stakeholders.