Job description

• Responsible for handling complex and escalated inquires and complaints, taking ownership through resolution.
• Observes and gathers evidence regarding care and other complaints.
• Provide accurate, prompt, and courteous service in response to member expression of dissatisfaction received through Contact Center, Care Partnership EOHHS teams, the Ombudsman or via CTM.
• Responsible for communication and member outreach related to the escalated clinical member complaints.
• Regularly collaborates with member, care team, clinical staff, family, and others involved in providing care for our members in resolving member escalations.
• Act as a liaison between A&G and clinical department along with multiple departments to ensure the timely and complete capturing and processing of clinical grievances. Communicates and documents for Interdepartmental stakeholders include but are not limited to: Quality, Regulatory affairs/Compliance, Clinical, Operations, Pharmacy, Dental, and Contact Center.
• Accurate and timely documentation to satisfactory resolution of member grievance.
• Assure timely completion of member verbal and written correspondence.
• Monitors ongoing trends in clinical grievances and participates in strategies for systemic resolution.

• Associate Degree in Social or Human Services required. Bachelor of Social Work (BSW) or Master of Social Work (MSW) preferred.
• Healthcare experience in hospital, community organization or health plan required. Previous Appeals and Grievance experience preferred.
• Training in motivational interviewing preferred.
• Strong interpersonal skills, verbal and written communication
• Demonstrates professional judgement skills
• Excellent listening skills
• Working with diverse member and providers; socioeconomically, ethically and culturally.
• Ability to resolve issues while maintaining professional and calm demeanor.
• Knowledge of federal and state laws, rules, and regulations for Medicare and Medicaid.
• English required, Bilingual in Spanish or Portuguese preferred.
• Completion of Ombudsmen certification within a year preferred.

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