Job Description

Location: Tamuning,None,Guam

Job Summary:

Reports directly to the Medical Management Manager and responsible for receiving, documenting, researching, responding to and contacting members about their eligibility, coverage inquiries, coordinated care and billings for services. Gathers and presents all relevant data relating to care management and coordination for review and approval including recommendation for resolution. Also responsible for coordinating problem resolution for members, providers, and employer groups amongst various internal departments and external resources/contacts.

Essential Duties & Responsibilities:

• The Patient Advocacy Representative functions as Patient Representative and Advocate for TakeCare members.
• Communicate member-related coordination and coverage problems or issues with Medical Management, Claims, Customer Service and other departments as appropriate.
• Assist in maintaining list of members to ensure monitoring, reporting and timely written and/or verbal follow-up on all members’ coordination, coverage and billing complaints and issues. Collaborate with other departments as needed for member satisfaction.
• Support the Medical Management team in care coordination and approval of covered services.
• Communicate and interact with members relating to their eligibility, coverage and care options on and off site.
• Receives, documents, researches and responds to member inquiries, and issues relating to care coordination, service approval and claims billings.
• Gathers and presents all relevant information relating to case and care coordination, medical review and provides recommendation for care coordination and approval pathway.
• Prepares and/or initiates a variety of correspondence/documentation in response to inquiries, and issues relating to care coordination, service approval and claims billings.
• Coordinates problem resolution for members, providers, and employer groups amongst various internal departments and external resources/contacts.
• Educates members on benefit coverage, coverage and coordination processes, and claims billing.
• Helps with the preparation of the monthly statistic reports for care coordination and referrals for Dashboard reporting to management.
• Performs other duties that may be assigned from time to time.

Education & Experience:

1. Graduate of associate degree or four (4) year course or work experience equivalence
2. Working knowledge of medical terminology
3. Must be able to demonstrate exceptional written/oral communication skills
4. Ability to interface with all sorts of people and handle difficult situations when necessary
5. Demonstrates superior customer service and problem solving skills as well as strong computer skills
6. Ability to maintain confidentiality
7. Minimum of 3 years’ experience in care coordination, member issue resolution, issue documentation and member communication.
8. Must have behavioral sensitivity, maturity, diplomacy and tact in complex situations and handling irate customers.
9. Must have basic familiarity on federal and state laws and requirements relating to healthcare management.
10. Strong ethics and a high level of personal and professional integrity.
11. Work independently with minimal to no supervision off-site if necessary.

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