Member Rights and Benefits Consultant

HealthPartners is hiring a Member Rights and Benefits Consultant. This position is responsible for understanding, investigating, presenting, resolving and effectuating the timely resolution of member grievances, dispute resolution process and/or appeals. The consultant may focus on thoroughly investigating member requests, supporting the formal complaint and appeal resolution process, mitigating risk by identifying compliance concerns and/or providing customer service and member education. The consultant makes sure that the outcome is fair, equitable and in alignment with all federal and state regulations and accreditation standards. Develop relationships with internal and external departments in order to effectively resolve member concerns. Each complaint must be documented clearly, thoroughly, timely and accurately on HealthPartners Customer Service System in order to ensure accurate tracking, reporting and outcomes.

ACCOUNTABILITIES:

The consultant may be responsible for any of the following responsibilities:

• Investigate member concern and ensure that all necessary documents are compiled, reviewed and presented to appropriate decision maker.
• Research, understand and ensure compliance with all federal, state, Medicare and Medicaid regulatory requirements and accreditation standards. Responsibilities also include ensuring HealthPartners policies match those of the appropriate regulatory agency.
• Develop partnership with other areas such as legal, medical directors, medical policy, pharmacy, behavior health, government programs, etc., in order to work efficiently and effectively to resolve member concerns.
• Communicate response to member or their authorized representatives and physician within internal and regulatory timeframes. Letter must include member friendly language (service recovery) and meet all federal and state requirements. Must use appropriate laws (federal, state) to support decision.
• Advise and assist members in pursuing their appeal options.
• Document complete complaint file. Each file must include accurate documentation of the complaint, timeliness and outcome. All files must comply with regulatory and organizational rules. Files are subject to subpoena and are used for reporting, audits and 2nd level appeals etc.
• Prepare case file, support and present case for each complaint that involves a second level complaint. Second level review may include, Member Appeals Committee, State fair hearings, MAXIMUS, External Review etc.
• Provide data for the quality assurance process to assist in identifying trends and areas where quality improvement strategies should be focused.
• Accurately record complaint in HealthPartners Customer Service System. Provide necessary documentation for data collection effort used to analyze member concerns and to report on them to the Board of Directors, Minnesota Department of Health CMS, DHS, Medical Directors, Government Programs and other interested departments/agencies.
• Provide information regarding the actions taken on specific cases to various departments.
• Provide technical expertise to legal staff on actions taken in response to cases that are the subject of litigation or regulatory dispute.
• Investigate and respond to regulatory agency inquiries, including the Minnesota Department of Health, Attorney General's Office, Department of Human Services, Centers for Medicare and Medicaid, StratisHealth and the Minnesota Department of Commerce. Provide accurate and detailed information that represents HealthPartners' policies, procedures and actions taken in response to specific member complaints.
• Consultants work with various internal departments to develop and implement benefit changes, contract provisions and policies to ensure regulatory compliance and improved member satisfaction. Resource for member advocates such as Legal Aid, regulators and Ombudsman's office.

The consultant may perform any of the following duties:

1. Investigate and respond to written or oral member complaints. Complaints may be standard or expedited. Investigate information necessary to make a decision. Review information with the appropriate medical administrative department head and other concerned parties.
2. Provide customer service to members, their representatives, and providers on the Medical Appeal Line.
3. Assess Appeal Line calls and written complaints and appeals to determine the most appropriate process for handling and resolution to improve the member experience.
4. In cases where the answer provided by Member Services is partially or wholly adverse to the member's request, inform the member of options for further consideration. This may include the Board of Director's Member Appeals Committee, written reconsideration, Minnesota Department of Health, Minnesota Department of Commerce, MAXIMUS, State fair hearing and Plan Administrator. Options vary depending on the contract.
5. In cases where the complaint decision is in the member's favor, ensure the decision is quickly and appropriately effectuated within regulatory timeframes.
6. Participate with Member Services Supervisors in an internal complaint review committee.
7. Consult with Member Services Representatives to provide advice concerning problem-solving specific issues and information regarding the complaint process.
8. Participate in business continuity planning and implementation.
9. Other duties as assigned by management.
   

REQUIRED QUALIFICATIONS:

• BA/BS or similar experience in a related field plus 2 years experience in a customer service position in a health related industry involving customer contract, problem resolution and written communication with customers.
• Excellent oral and written communication skills. Ability to express ideas clearly. Ability to communicate HealthPartners policy and procedures.
• Ability to understand and explain complex medical policies and services. This must include proficiency with medial terminology and ability to summarize medical records and reports.
• Advanced problem solving and investigative skills, with the ability to develop creative solutions for complex problems. Willingness and ability to model outstanding customer service and service recovery.
• Ability to identify problems, to do in-depth investigation, develop and assess alternative courses of action, and make sound and timely decisions. Ability to develop working relationships with a number of internal departments in order to resolve issues.
• Ability to negotiate with members, internal departments or providers in difficult situations.
• Proficient at a number of computer software programs.

PREFERRED QUALIFICATIONS:

• Work experience in a managed-care setting involving significant contact with members and providers.
• Professional writing experience beyond an educational setting.
• Experience interpreting regulatory/statutory guidelines.