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Date Added: Sat 11/09/2021

Member Advocate - Pruitthealth Premier

Charlotte, NC, US
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Job Type: Permanent, FullTime


PruittHealth is a COVID-19 vaccine-mandated employer. All new Partners are required to provide proof of COVID vaccination or be willing to get vaccinated within 30 days of employment. We will consider medical and/or religious exemptions on a case-by-case basis.
We have established the Member Advocate role for PruittHealth Premier to serve as a customer service liaison for our enrolled members, their families, healthcare providers and our skilled nursing facility partners. They help resolve member complaints, provider access issues, claims concerns, conduct network outreach, help ensure access to supplemental benefits and provider, and assist with transitions out of PruittHealth Premier. In addition, they provide ongoing education to our in-network skilled nursing facility staff and conduct facility visits and process audits to ensure the facilities are both satisfied with our service and following required plan processes.

1. Meet with new members/responsible party to ensure that any questions are answered, act as a point of contact if the member or their family needs assistance with the plan or provide them with periodic updates about the plan.
2. Act as front-line support as needed with the member, partner facility and integrated care team to ensure the needs of the Member and Plan are met.
3. Develop and maintain relationships with key network providers/facilities within assigned region; support continued regional network development activities necessary to meet network adequacy requirements.
4. Meet with the member and/or their family as needed for complaints/concerns.
5. Resolve member /family issues within 72 hours or escalate to the appropriate party.
6. Assist with claims issues with members or providers, working with the AAH account manager.
7. Assist with the PHP provider network and appointment scheduling when necessary
8. Conduct yearly customer service surveys with the member and/or their family; based on the results of the survey, follow up on any items that the members are dissatisfied with.
9. Organize in-service educational training sessions with key facility staff monthly.
10. Conduct orientation with new key facility staff within 30 days of hire utilizing position checklist of required training sessions.
11. Develop and maintain reporting to include but not limited to managing member status, daily/weekly/monthly facility calendar, issues tracking/management
12. Ensure that all interactions with the member are compliant with CMS regulations
13. Conduct monthly facility audit in accordance with monthly checklist provided.
14. Send monthly roster to each facility based on list of contacts provided by the administrator including any Fist provided.
15. Assist member and responsible party with transitions out of the plan to include education on coverage options once disenrolled, review the member discharge handout, provide a copy of their insurance card and appointment packet.
16. The Member Advocate will be responsible for a group of nursing facilities; the Member Advocate is responsible for ensuring that the above services are carried out for each of the members in your assigned group of facilities


• Demonstrate compliance with CMS regulations regarding Medicare Advantage Plans and PruittHealth Code of Conduct.

• Demonstrate exceptional interpersonal skills with ability to work independently as well as with a team; must be a good listener to understand feedback raised by the potential member/family; provider, etc.

• Exceptional organizational skills: strong written and verbal communication and clear-thinking skills with the ability to synthesize complex issues into simple messages.

• Ability to work well with staff at each of the nursing homes in the assigned region to include program director, nursing staff, doctors, and administration staff

• Deliver outstanding customer service.

• Willingness and ability to travel to facilities within your assigned region; have dependable transportation, a current driver’s license, a clean driving record, and proof of insurance.

• Strong proficiency in computer skills in Microsoft Office Suite products.

• Have suitable home workspace allowing for productive office environment.

• Understands the PruittHealth Premier Plan benefits, PruittHealth Premier Plan policies, procedures and articulate them effectively to providers, members, and key decisions makers.


Bachelor’s degree required

2 years healthcare related experience preferred.
Good communication skills and organizational skills needed
Ability to work well with staff at each of the nursing homes in the assigned region to include program director, nursing staff, doctors, and administration staff.
Ability to deliver outstanding customer service.

ADDITIONAL QUALIFICATIONS: (Preferred qualifications)

•AHIP Certification and Licensed to sell Life and Health insurance in required states to act as an enrollment agent if necessary.

Job: Administrative
Primary Location: North Carolina-Charlotte
Schedule: Full-time
Shift: 1st Shift
Job Posting: Sep 7, 2021, 8:00:56 PM
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