We are searching for a Member Advocate — someone who works well in a fast-paced setting. Investigates resolves and facilitates 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.

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Job Duties & Responsibilities

Educates members about their rights and responsibilities, which includes the complaints and appeals process
Advocates for members during complaints, appeals, and fear hearings; complies with 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
Responds to internal system trouble notifications and, if necessary, coordinates the involvement of other departments to facilitate problem resolution
Serves as a continual resource for team member questions, concerns, etc.; viewed as being a primary available and approachable resource to team members
Evaluates, monitors, and coordinates community resources
Coordinates with DARS and local resources for the identification and support of employment and training opportunities for members
Identifies options and initiates collaboration with referral sources to ensure member/family linkage to specialists, home care providers, financial assistance, housing, meals, transportation, and other community resources as appropriate for members with unmet needs
Evaluates, monitors, and coordinates community resources and maintains current knowledge of local and state resources
Coordinates with DARS and local resources for the identification and support of employment and training opportunities for members
Identifies options and initiates collaboration with referral sources to ensure member/family linkage to specialists, home care providers, financial assistance, housing, meals, transportation, and other community resources as appropriate for members with unmet need
Assists manager in identifying opportunities for process and service improvement initiatives. Participates in the development and implementation of action plans

Skills & Requirements

H.S. Diploma or GED
2 years’ experience customer service experience within managed care or insurance industry

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 15,000+ 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.

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