Ombudsman (Medicaid / Florida Health Plan) - REMOTE

Molina Healthcare•Long Beach, FL

21d•Remote

About The Position

Description JOB DESCRIPTION Provides support for member advocacy activities. Responsible for resolution of member issues including investigating and resolving member grievances, identifying systemic challenges affecting the member experience, and advocating for member rights. Essential Job Duties Plays a pivotal role in ensuring the well-being and satisfaction of members by addressing their concerns with a commitment to impartiality and independence. Listens to member concerns and ensures members understand their rights and responsibilities. Investigates member issues and works to find appropriate and fair resolutions; this includes addressing systemic issues impacting member ability to access health care services, provision of timely support from care management staff or other personnel, billing and communication support, and any other support needs related to the member experience. Ensures that member rights are upheld and respected throughout their health care journey. This includes protecting member confidentiality, promoting informed consent, and ensuring cultural sensitivity and diversity; collaborates with relevant stakeholders to improve the overall quality of services provided to members under covered programs. Provides information about available resources to members and assists with navigating the health care system. Represents members on internal issues - investigates complaints thoroughly and impartially, gathering relevant information, interviewing involved parties, and reviewing medical records, policies and procedures. Documents all interactions, complaints, investigations, and resolutions in a timely and accurate manner. Prepares reports and statistical analyses to identify trends and areas for improvement. Collaborates with health care professionals, administrators, and staff to address member concerns, develop strategies for quality improvement, and promote a member-centered approach to care. Conducts educational sessions for members, member families, and health care staff on member rights, and effective communication strategies; travels and participates in all Molina member advisory boards for covered programs statewide. Remains knowledgeable about relevant laws, regulations, and policies about member rights and health care quality; applies this knowledge to ensure compliance and advocates for necessary change when required. Collaborates with other applicable departments and committees within the organization to implement initiatives that enhance member satisfaction, improve processes, and promote a culture of member-centered care. Presents and reports findings/recommendations to the appropriate channels and health plan leadership.

Requirements

At least 3 years of experience in a managed care environment, preferably in a Medicaid environment, or equivalent combination of relevant education and experience.
Knowledge of state Medicaid policies and programs.
Customer service and interpersonal skills; ability to empathize, remain calm under pressure, and build rapport with a diverse range of individuals.
Problem-solving and conflict resolution skills to address and resolve complex member/patient complaints and conflicts.
Ability to maintain strict confidentiality and handle sensitive information with integrity.
Sound judgment and decision-making abilities to assess situations, evaluate evidence, and recommend appropriate actions.
Proficiency in record-keeping and data management to accurately maintain and analyze complaint records and statistics.
Knowledge of health care systems, patient/member rights, and relevant laws and regulations.
Ability to work independently and make impartial decisions while adhering to professional ethics and standards.
Proficient in use of computer systems, software, and databases for documentation and data analysis.
Ability to navigate a large and complex matrixed organization.
Organizational and time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines.
Effective verbal and written communication skills, including ability to communicate with internal and external stakeholders, members, families, and health care providers.
Microsoft Office suite and applicable software programs proficiency.
Specific health plans may require state residency.

Nice To Haves

Member advocacy or complaint resolution experience in a health care setting.
Developed understanding relevant state and federal regulations and accreditation standards, such as Health Insurance Portability and Accountability Act (HIPAA), and Centers for Medicare and Medicaid (CMS) guidelines.
Developed understanding of member rights, medical ethics, and health care quality improvement initiatives.
Developed understanding of health care processes, medical terminology, and the health care delivery system.
Certification in conflict resolution or ombudsman service.
Certification in patient/member advocacy or related field.

Responsibilities

Listens to member concerns and ensures members understand their rights and responsibilities.
Investigates member issues and works to find appropriate and fair resolutions
Ensures that member rights are upheld and respected throughout their health care journey.
Provides information about available resources to members and assists with navigating the health care system.
Represents members on internal issues - investigates complaints thoroughly and impartially, gathering relevant information, interviewing involved parties, and reviewing medical records, policies and procedures.
Documents all interactions, complaints, investigations, and resolutions in a timely and accurate manner.
Prepares reports and statistical analyses to identify trends and areas for improvement.
Collaborates with health care professionals, administrators, and staff to address member concerns, develop strategies for quality improvement, and promote a member-centered approach to care.
Conducts educational sessions for members, member families, and health care staff on member rights, and effective communication strategies; travels and participates in all Molina member advisory boards for covered programs statewide.
Remains knowledgeable about relevant laws, regulations, and policies about member rights and health care quality; applies this knowledge to ensure compliance and advocates for necessary change when required.
Collaborates with other applicable departments and committees within the organization to implement initiatives that enhance member satisfaction, improve processes, and promote a culture of member-centered care.
Presents and reports findings/recommendations to the appropriate channels and health plan leadership.