Ombudsman (Medicaid / Florida Health Plan) - REMOTE

JOB DESCRIPTION Provides support for member advocacy activities. Responsible for resolution of member issues including investigating and resolving member grievances, identifying systemic challenges affecting the member experience, and advocating for member rights. Essential Job Duties u2022 Plays a pivotal role in ensuring the well-being and satisfaction of members by addressing their concerns with a commitment to impartiality and independence. u2022 Listens to member concerns and ensures members understand their rights and responsibilities. u2022 Investigates member issues and works to find appropriate and fair resolutions; this includes addressing systemic issues impacting member ability to access health care services, provision of timely support from care management staff or other personnel, billing and communication support, and any other support needs related to the member experience. u2022 Ensures that member rights are upheld and respected throughout their health care journey. This includes protecting member confidentiality, promoting informed consent, and ensuring cultural sensitivity and diversity; collaborates with relevant stakeholders to improve the overall quality of services provided to members under covered programs. u2022 Provides information about available resources to members and assists with navigating the health care system. u2022 Represents members on internal issues - investigates complaints thoroughly and impartially, gathering relevant information, interviewing involved parties, and reviewing medical records, policies and procedures. u2022 Documents all interactions, complaints, investigations, and resolutions in a timely and accurate manner. u2022 Prepares reports and statistical analyses to identify trends and areas for improvement. u2022 Collaborates with health care professionals, administrators, and staff to address member concerns, develop strategies for quality improvement, and promote a member-centered approach to care. u2022 Conducts educational sessions for members, member families, and health care staff on member rights, and effective communication strategies; travels and participates in all Molina member advisory boards for covered programs statewide. u2022 Remains knowledgeable about relevant laws, regulations, and policies about member rights and health care quality; applies this knowledge to ensure compliance and advocates for necessary change when required. u2022 Collaborates with other applicable departments and committees within the organization to implement initiatives that enhance member satisfaction, improve processes, and promote a culture of member-centered care. u2022 Presents and reports findings/recommendations to the appropriate channels and health plan leadership. Required Qualifications u2022 At least 3 years of experience in a managed care environment, preferably in a Medicaid environment, or equivalent combination of relevant education and experience. u2022 Knowledge of state Medicaid policies and programs. u2022 Customer service and interpersonal skills; ability to empathize, remain calm under pressure, and build rapport with a diverse range of individuals. u2022 Problem-solving and conflict resolution skills to address and resolve complex member/patient complaints and conflicts. u2022 Ability to maintain strict confidentiality and handle sensitive information with integrity. u2022 Sound judgment and decision-making abilities to assess situations, evaluate evidence, and recommend appropriate actions. u2022 Proficiency in record-keeping and data management to accurately maintain and analyze complaint records and statistics. u2022 Knowledge of health care systems, patient/member rights, and relevant laws and regulations. u2022 Ability to work independently and make impartial decisions while adhering to professional ethics and standards. u2022 Proficient in use of computer systems, software, and databases for documentation and data analysis. u2022 Ability to navigate a large and complex matrixed organization. u2022 Organizational and time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines. u2022 Effective verbal and written communication skills, including ability to communicate with internal and external stakeholders, members, families, and health care providers. u2022 Microsoft Office suite and applicable software programs proficiency. u2022 Specific health plans may require state residency. Preferred Qualifications u2022 Member advocacy or complaint resolution experience in a health care setting. u2022 Developed understanding relevant state and federal regulations and accreditation standards, such as Health Insurance Portability and Accountability Act (HIPAA), and Centers for Medicare and Medicaid (CMS) guidelines. u2022 Developed understanding of member rights, medical ethics, and health care quality improvement initiatives. u2022 Developed understanding of health care processes, medical terminology, and the health care delivery system. u2022 Certification in conflict resolution or ombudsman service. u2022 Certification in patient/member advocacy or related field. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V #PJCorp #LI-AC1 Pay Range: $49,930 - $97,363 / ANNUAL Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Created: 2026-02-16