Member Advocacy Coordinator

About the role

The Member Advocacy Coordinator serves as a dedicated quality, research, and investigative resource within the Customer Service department. This role oversees oral dissatisfaction, coverage determination, and organization determination (ODAG), and service recovery cases from intake to ensure proper intake is adequate for first-call resolution or that additional information is required to update and route to the appropriate department for resolution. The coordinator conducts case research, reviews member interactions and documentation, identifies trends and opportunities for process improvement, and partners with leadership to improve the member experience, quality, and compliance. The role primarily focuses on investigation and on coordinating cross-functional communication between Health Plan departments to ensure accurate issue resolution.

Responsibilities

• Handle a high volume of Oral Dissatisfaction, Appeals, and Grievance (ODAG) cases from verbal intake through resolution, conducting research and investigation as needed to ensure concerns are appropriately addressed or routed to the correct department for resolution.
• Ensure accurate documentation, timely follow-up, and compliance with contractual and regulatory turnaround time requirements for member communications.
• Review, triage, and route ODAG cases within designated tracking systems, ensuring all work is completed with a high degree of accuracy, quality, and attention to detail.
• Maintain comprehensive case documentation, including detailed ODAG notes, research findings, member outreach efforts, resolution activities, and all supporting information necessary to support effective case management, regulatory compliance, and timely resolution.
• Assist in communicating and escalating member and provider feedback to appropriate stakeholders, including Appeals & Grievances, Provider Appeals, Operations, and other business areas.
• Analyze recurring themes and trends, and provide recommendations to enhance reporting, strengthen operational insights, and improve processes, service delivery, and member experience outcomes.
• Prepare and maintain case files for CMS, HPMS, and other high-priority escalations, ensuring all supporting documentation, research, and responses are complete, accurate, and submitted within established regulatory and contractual deadlines.
• Provide members with helpful, appropriate information on an ongoing basis as you resolve their issues.
• Coordinates with appropriate departments to resolve payment and claims processing issues and to identify system improvements that will, in turn, reduce member appeals.

Qualifications

Education

• High School Diploma or Equivalent required
• Associate's Degree Related Field of Study preferred

Experience

• Health plan experience, ideally within customer service, quality, or appeals and grievances area: 3-5 years required
• Administrative experience: 2-3 years preferred
• Billing and Claims experience: 2-3 years preferred

Knowledge, Skills And Abilities

• Strong aptitude for technology-based solutions
• Strong customer service skills
• Excellent communication skills
• Ability to adapt to changing priorities and work effectively in a dynamic environment
• Excellent organizational abilities to manage multiple tasks, prioritize work, and meet deadlines

Additional Job Details

M-F 8 AM - 5 PM EST hours required for remote role. A quiet, secure, stable, HIPAA-compliant workstation is required.

Pay

$22.22 - $31.71/Hourly

Schedule

Day (United States of America)