Kforce Member Advocate in Saint Louis, Missouri

Kforce has a client in search of a Member Advocate in Saint Louis, Missouri (MO).Responsibilities include:

  • Develops and maintains processes to evaluate complaints, grievances and appeals trends to support administrative and clinical performance improvement tools and initiatives

  • Facilitates and provides administrative support for the Grievance and Appeals Committee

  • Administers the Notice of Action process in accordance with the applicable State and health plan guidelines

  • Interacts with health plan, regulatory and accreditation representatives including medical directors, clinical personnel and administrative staff

  • Provides coordination with medical services as necessary in performing member advocacy functions-working with providers, health plan and facility for members

  • Maintains compliance with regulatory, health plan, and accreditation requirements related to the denial or reduction of services

  • Administers member and provider complaints, grievances and appeals within the designated time frames to maintain performance standards

  • Tracks each complaint, grievance and appeal by documenting the stage and person responsible as they move through the process within timeline performance standards; Investigates complaints, grievances and appeals and all necessary correspondence to support their investigation and resolution

  • Provides the Manager, Quality and Utilization Management and other internal staff monthly reports on complaints, grievances and appeals activities and their status

  • Participate and prepare summaries of utilization management and member/provider information for Quality Committee meetings

  • Coordinates Provider Retro Review and Appeals

  • Maintains confidentiality of all written or electronic communications

  • Attends internal and external meetings as required

  • Other duties as assigned

  • Two-year Associate degree or a minimum 5 years of managed care or clinical dental experience required

  • Certification from AHCCCS preferred

  • Proficient in use of Microsoft Office

  • Excellent organizational skills and attention to detail

  • Strong oral and written skills

  • Strong interpersonal skills

  • Good team player with strong self-motivation and self-direction abilities

  • Must be able to learn/use in-house systems for Customer Service, Claims and other related systems

  • Proven subscription to the company's core values of integrity, trust and respect, innovation, stewardship, excellence and celebration

  • Professional appearance and demeanor

Kforce is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, pregnancy, sexual orientation, gender identity, national origin, age, protected veteran status, or disability status.Compensation Type:Hours