Member Advocate Specialist - Lufkin or Nacogdoches

Company: DentaQuest ( Learn More )

General Information
US-TX-Nacogdoches
N/A
Not Specified
Full-Time
At least 5 year(s)
Not Specified
False
False
Job Description

 *Ideal candidate must be located in Lufkin or Nacogdoches*

The Member Advocate Specialist has direct oversight for the advocacy of members included but not limited to preventive dental care, access to care, education, complaints and grievances, appeals, and dental home.  In addition, attendance at health fairs and community events as needed.   

JOB RESPONSIBILITIES:

  • Facilitate the delivery of preventive dental services for eligible members every six months beginnings six months of age. 
  • Facilitate the delivery of preventive dental services for new members within 90 days of enrollment.
  • Ensure members receive educational materials upon enrollment regarding the services available through the Texas Health Steps program and how to obtain them. Educational material also includes information on:
  • Member’s rights and responsibilities
  • The complaint process
  • The appeal process
  • Medically necessary covered services available to them, including preventive services
  • Non-capitated services
  • Assist Children of Migrant Farm Workers receive prompt delivery of service, as they might transition into and out of the dental program more rapidly than the general population. This includes coordinating with their provider to make certain they receive preventive dental services prior to leaving Texas (“accelerated services”) if their routine checkup is scheduled after they leave Texas.
  • Understand the cultural and socio-economic characteristics of their region(s). Develop a strong presence in local communities through partnering with organizations that advocate for and serve low income children. These relationships will aid in the member advocate’s ability to refer members to community resources that can accommodate members’ needs if the services are not medically necessary covered dental services.
  • Assist members, either in person or via telephone, with writing complaints. Responsible for monitoring complaints through completion.
  • Collaborate with customer service staff to ensure members are contacted for dental appointments to be scheduled in a timely manner (within 30 days for routine care).
  • Establish and maintain a process to manage dental care and continuity of care for individuals with special health needs.
  • Collaborate with DentaQuest management, internal departments, and HHSC to plan, evaluate and implement activities to improve access and appropriate care to members. This includes making recommendations on changes that may improve either the care provided or the way care is delivered.
  • Manage all aspects of the dental home process in their region. This includes tasks such as assisting members with finding a dental home, coordinate case management for various populations including special needs and Children of Migrant Farm Workers, maintaining the data for reporting dental home activities, and coordinating outreach efforts.
  • Submit tracking and trending reports related to dental home, member advocacy, migrant worker, care coordination and case management performance measures to DentaQuest management.  Identify disparities, opportunities for improvement and recommended solutions.
  • Help maintain and increase dental access requirements in compliance with dental home components, Medicaid, CHIP and Frew guidelines.
  • Adhere to DentaQuest business processes.
  • Other duties as assigned.
  • Required Skills

  • Knowledge of healthcare advocacy activities is preferred.
  • Bilingual language skills highly preferred.
  • Creativity in promoting events and implementation of events is preferred.
  • Demonstrated commitment to health and wellness.
  • Self-motivated, and ability to work with little supervision.
  • Strong analytical skills.
  • Strong problem solving skills and the ability to make independent decisions. 
  • Strong written and oral communication skills.
  • Knowledge of general computer software (Outlook, Excel and MS Word)
  • Job Requirements

    • 5+ years of related experience in healthcare, advocacy or customer service. 
    • Demonstrated proficiency in claims processing and issue resolution. 
    • Knowledge of clinical and industry terminology and procedures.
    • Experience working in a managed care environment is preferred