Excellus Health Plan Inc.
Advocacy Associate I/II-007540 (Education)
Summary Essential Responsibilities/Accountabilities Level II – Performs similar functions as Level I, plus:
Under general guidance of the Supervisor of Advocacy Unit, this position is responsible for the research and processing of Grievances, Appeals, Intangibles and Inquiries for both members and providers, for all lines of business (may include Medicare Advantage or Medicare PDP plans). This includes in-depth research, analysis, decision making within prescribed guidelines, written or oral communication to management and the provider or member. The associate works closely with Legal, Compliance, Medical Directors and other departments to gather the necessary information in an expeditious manner. Associate regularly exercises judgment and decision making, based on regulatory requirements, through case work. Associate must demonstrate excellent oral and written communication skills, using the appropriate style and reading level for the line of business. Makes recommendations for problem resolution for issues the Advocacy Associates are involved in which originated from customers, providers and groups. The Advocacy Associate must demonstrate the ability to effectively organize, manage and prioritize their work to meet the departmental and regulatory requirements.
All Levels
• Responsible for working grievances, appeals, inquiries and intangibles for all lines of business regardless of timeframes.
• Opens mail – scans documents and forwards to Intake for loading
• Compiles and provides Designated Record Set (DRS) to member
• Compiles and provides DOL Requests for Information (RFI) to member.
• Assesses and determines the correct course of action for assigned cases.
• Organizes and prioritizes based on the requirements for case type and line of business.
• Effectively researches issues, gathers necessary corporate policies, medical records, contracts and/or reference materials in order to evaluate if any additional information is necessary to make a decision.
• Renders decisions, within reasonable latitude, given the circumstances of the case, and follows regulated requirements for case reviews. At times facilitates the case decision made by Legal.
• Provides written and/or oral responses to all cases/inquiries in appropriate business formats ensuring that the decision is communicated clearly and at the appropriate reading level to the customer as these decisions are binding for the corporation.
• Proactively communicates with all levels of internal and external customers.
• Ensures cases are worked within all regulated time frames.
• Escalates issues identified through daily case work.
• Meticulously documents cases in a timely and professional manner ensuring that cases are easily understood.
• Maintains a computer database for tracking cases and logging other inquiries received in Advocacy Unit.
• Evaluates and manages own inventory and proactively brings any inventory concerns are to their Team Leader with their proposed plan of action to ensure department and regulatory requirements are met.
• Maintains an accurate filing system on research resulting in the decisions that can be used for benefit challenges, or in court legal proceedings.
• Must be familiar and stay informed with State/Federal laws and negotiations, government regulations with emphasis on the Managed Care Reform Act, all Managed Care Legislation, and ERISA legislation that could/would affect contracts and the customers.
• Keeps abreast of developments germane to the function by attendance at seminars and workshops. Reads publication reviews, and completes independent study.
• Overseen by management/training department on case work during the training phase and while gradually becoming independent.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and Leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular reliable attendance is expected and required.
• Performs other functions as assigned by management.
• Develops and initiates processes throughout the organization that results in streamlining the current handling of Grievance, Appeals, Intangibles and Inquiries.
• Responsible for the handling of Level 2 Grievance and Appeals Cases
• Escalates issues outside of scope of authority as identified through daily case work.
• Responsible for managing the Advocacy hotline.
• Provides coverage/backup for both scheduled and unscheduled absences of peers and level 1 advocate staff.
• Sits in on various corporate committees and/or projects as assigned by management.
Minimum Qualifications
Level I
NOTE:
We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.
• High School Diploma or GED.
Minimum of one year of related experience or training in customer operations and/or medical management areas. Level II – similar minimum qualifications as level I required except for:
• Knowledge of claims processing systems, contracts, and riders preferred.
• Must demonstrate exceptional organizational and time management skills.
• Familiar with government regulations including but not limited to, Managed Care law, UR Law, DOL/ERISA legislation and Health Care Reform preferred.
• Ability to demonstrate an understanding at a detailed level of clinical editing logic, claims processing, Interqual criteria and corporate medical policies preferred.
• Requires excellent oral and written communication skills.
• General knowledge of insurance policies, procedures, and rules, plus federal and state activities as they relate to subscriber's rights preferred.
• Must be able to effectively communicate with all levels of employees in the corporation as well as members and providers.
• High School Diploma or GED.
• Minimum of three years of related experience or training in customer operations and/or medical management areas. Physical Requirements
• Advanced knowledge of automated claims processing systems, and an overall understanding of insurance contracts and riders required.
• General knowledge of insurance policies, procedures, and rules plus federal and state activities as they relate to subscriber's rights required.
• Must be able to demonstrate proficiency in most case types and inquiries handled within the unit.
• Must be able to effectively communicate with Regulatory agencies.
• Consistently able to demonstrate independent decision making with minimal guidance from the management/training teams.
• Ability to sit for extensive periods of time reviewing information on a computer screen
• Ability to travel across regions as required.
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Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce. OUR COMPANY CULTURE: In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
The Lifetime Healthcare Companies aim to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.
Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.
Equal Opportunity Employer
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)
Non Manager