Alameda Alliance for Health jobs - 373 jobs

Medicare Field Sales Agent - Bilingual Cantonese / Job Req 906241555
Alameda Alliance for Health 4.6
Alameda Alliance for Health job in Alameda, CA
Hybrid: Applicants must be a California resident as of their first day of employment. PRINCIPLE RESPONSIBILITIES: The Medicare Field Sales Agent is responsible for compliantly achieving established monthly, quarterly, and annual Medicare Advantage (D-SNP) new enrollment and retention goals. Consistently enrolling self-generated, Partner generated, and company generated Medicaid conversion and marketing leads is essential to this role's success. The agent must work in collaboration with their team members and other Alameda Alliance for Health (AAH) department personnel to develop and execute an effective growth and retention strategy. A key part of that strategy will require them to work effectively and leverage relationships with providers, community organizations, and other influencers. Their engagement will take the form of participation in or sponsorship of local community events, individual provider co-marketing programs and targeted member outreach activities in conjunction with community partners. Medicare Field Sales Agent will report to the Manager of Medicare Sales and Retention. The incumbent will be assigned specific responsibilities as determined by their manager based on opportunities identified related to product offerings, geographic or other market segmentation criteria. The agent will be expected to generate new enrollments and achieve established retention targets through consistent and thoughtful member and prospect engagement activities. The agent must consistently complete proven "best practice" based activities to develop and manage their territories and/or assignments and provide regular status reporting at predetermined intervals via the sales departments established activity and performance tracking system. The agent will be expected to comply with all CMS, DMHC, and DHCS guidelines and quickly report any potential issues to their manager or Chief Compliance Officer. Principle responsibilities include: * Expected to achieve all established enrollment and retention objectives. * Putting the member or prospective members needs first and assisting them in their efforts to enroll with AAH via whatever channel best meets their needs, i.e. face-to-face, online, group setting, telephonic. * Responsible for professionally representing AAH Medicare D-SNP programs in the market to all members, prospects, providers, and partners. * Assisting prospective members in their efforts to understand AAH's products, services, mission, and unique value proposition. * Work with internal staff, providers and community partners to create or participate in programs to engage, educate, and enroll existing AAH Dual Eligible Medi-Cal members. * Provide staffing and support for member retention activities organized by the sales department or any of the Alliance's other departments. * Consistently evaluate their activities in relationship to established sales and marketing CMS and compliance guidelines. * Program requirements, including validation of data and internal controls. * Provide market-level feedback to their sales and marketing leaders related to the competitive landscape. * Understand how to use all core sales systems, i.e. lead and sales funnel management, weekly reporting, expense management, etc. * Work collaboratively and respectfully with all team members, company staff, partners, and providers. * Expected to practice good time and territory management behaviors, to ensure maximum performance. * Maturity to work independently. * Ability to work effectively and efficiently in a deadline-driven environment. * Adheres to all company policies and procedures relative to employment and job responsibilities. * Other duties as assigned. ESSENTIAL FUNCTIONS OF THE JOB: * Contacts: Manage the enrollment application process for all new members as established by Sales Leadership, CMS, and the Compliance Department. Work closely with Broker Agencies to recruit, train, and motivate them to enroll members, if applicable. * Conflict resolution: When member or prospect issues arise, respectfully capture the available information and quickly relay it to appropriate AAH department and personnel. * Member Communications: Provide feedback and collaborate with the appropriate department related to current materials or share insights or information on any changes that could improve the member's experience. * Computer: Utilize the existing systems provided by the organization to capture, track and report on all activities or information needed to ensure we continue to improve the experience of AAH members, partners, providers, and the community. * Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls. * Assumes responsibility and exercises good judgement in making decisions within the scope of authority of the position. * Be proficient in understanding Centers for Medicare and Medicaid Services (CMS) and DHCS/DMHC guidelines, as it relates to sales activities. * Provides support to the Project Management Office (PMO) and various enterprise-wide activities based on availability. * Organizes and facilitates sales project-related meetings, as necessary. * Works effectively independently as well as part of a team and supports team decisions. * Adapts to changes in requirements/priorities for daily and specialized tasks. * Produces accurate and precise work, detects discrepancies, and resolves discrepancies all while meeting deadlines. PHYSICAL REQUIREMENTS: * Constant and close visual work at a desk or a computer. * Constant sitting and working at a desk. * Constant data entry using a keyboard and/or mouse. * Frequent use of a telephone headset. * Constant verbal and written communication with staff and other business associates by telephone, correspondence, or in person. * Frequent lifting of folders and other objects weighing between 0 and 30 lbs. * Frequent walking and standing. * Occasional driving of automobiles to provider offices Number of Employees Directly Supervised: 0 Number of Employees Indirectly Supervised: 0 MINIMUM QUALIFICATIONS: EDUCATION OR TRAINING EQUIVALENT TO: * High school graduate or equivalent (GED) * Bachelor's degree preferred or equivalent experience. * 2025/2026 AHIP Certification required. * California Health and Accident or Life, Health and Accident License required. MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE: * Two (2) to four (4) years' related work experience in a Medicare Advantage (MA) Plan or Medicare Advantage Dual Special Needs Plans (MA-DSNP) required. * Required two (2) years Medicare Sales experience or in lieu, two (2) years selling or supporting seniors, including general understanding or Medicare and related products in either a face-to-face, or telephonic setting required. SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE): * The ability to speak and understand-bilingual: Spanish/English, Cantonese/English, Mandarin/English, Vietnamese/English, Tagalog/English, Arabic/English, Farsi/English are required as designated. * A bilingual proficiency exam will be administered to ensure the candidate possesses the appropriate skill level to meet requirements. The successful candidate must score 90% or higher. * Must live in or within reasonable driving distance to Alameda County, California. * Estimation of 60% salary base and 40% commission base based on tiered structure and business needs. * Willingness to occasionally work irregular hours based on business * Strong computer skills including proficiency in word processing, spreadsheet, and CRM database software skills required. * Good understanding of agency distribution channel management. * Basic knowledge of industry regulatory guidelines related to job functionality. * Ability to work independently. * Exceptional communication and interpersonal skills. * Excellent organizational skills and capability to handle multiple campaigns at one time. * Strong organizational skills with the ability to effectively prioritize multiple tasks and meet deadlines. * Good territory and funnel management skills. * Ability to maintain confidentiality related to sensitive matters. * Strong ethical foundation and trustworthy character. * The incumbent must have own vehicle and a valid driver's license with proof of insurance in conformity with state law minimums. SALARY RANGE $83,241.60 - $124,862.40 ANNUALLY The Alliance is an equal opportunity employer and makes all employment decisions on the basis of merit and business necessity. We strive to have the best-qualified person in every job. The Alliance prohibits unlawful discrimination against any employee or applicant for employment based on race, color, religious creed, sex, gender, transgender status, age, sexual orientation, national origin, ethnicity, citizenship, ancestry, religion, marital status, familial status, status as a victim of domestic violence, assault or stalking, military service/veteran status, physical or mental disability, genetic information, medical condition, employees requesting accommodation of a disability or religious belief, political affiliation or activities, or any other status protected by federal, state, or local laws.
$83.2k-124.9k yearly 17d ago

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Business Analyst / Job Req 872679172
Alameda Alliance for Health 4.6
Alameda Alliance for Health job in Alameda, CA
Applicants must be a California resident as of their first day of employment PRINCIPAL RESPONSIBILITIES: Under the general supervision of the Supervisor, IT Applications, the Business Analyst performs complex business process and data analysis with internal customers to gather business requirements for use in identifying innovative technology solutions and supporting system configuration to meet business needs. This position will be the liaison between business and technical teams to provide technical solutions, processes, system configuration and resolutions. Organization expects job performance to be consistent with its vision and mission. Day-to-day work is focused on these key performance areas. Percentages of time are estimates based upon observation in the position. Principal responsibilities include: * Lead work groups in business process analyses to determine the business needs of customers and implement the changes, additions, and improvements that are needed for Business Applications (i.e., Provider repository, quality applications, claims processing, enrollment, capitation) * Identify and analyze various user problems and make appropriate recommendations. Participate in upgrade/replacement/ new implementation projects by tracking activity, resolving problems, publishing progress reports, recommending actions and assisting with the management of vendor relationships. Collaborate with the Manager, Vendor Management as appropriate. * Determine operational objectives by studying business functions, gathering information, evaluating input and output requirements and formats. Improve systems by studying current practices, design modifications. * Configure, analyze, and audit core system current-use functionality and resulting data for best practices. This may include member enrollment, benefits, claims, assessments, authorization rules, correspondence, membership, fee schedules, provider and hospital contracts, as well as other system module configuration. * Recommend technology solutions and manage vendor functionality enhancements to meet the business needs of the AAH Departments. Document those needs and the resulting changes implemented. * Assist with the business case for new and upgrading systems. Conduct cost/benefit analysis. Define project requirements by identifying requirements, project milestones, phases, and elements. Help form project teams and establish project budget. Evaluate and plan systems training for upgrade/replacement/ new implementation projects. * Design, plan and conduct end-user training for a variety of software applications on desktop and laptop computers. * Other duties as assigned. PHYSICAL REQUIREMENTS * Constant and close visual work at desk or on a computer. * Constant sitting and working at desk. * Constant data entry using keyboard and/or mouse. * Frequent use of telephone headset. * Constant verbal and written communication with staff and other business associates by telephone, correspondence, or in person. * Frequent lifting of folders and other objects weighing between 0 and 30 lbs. * Frequent walking and standing. Number of Employees Supervised: 0 MINIMUM QUALIFICATIONS: EDUCATION OR TRAINING EQUIVALENT TO: * Bachelor's Degree or equivalent professional experience. MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE: * Six years of experience in business analysis. * Two years of experience in an operational healthcare or payer setting preferred. Two years of experience in research, analysis and/or business processes required. * Three years working knowledge of process functionality and understanding of business platform(s). SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE): * Ability to create diagrams such as Use Cases, DFD (Data Flow Diagrams), and others. * Knowledge of relational database systems, such as SQL or Microsoft. * Knowledge of the theory, principles, practices and methods of system analysis. * Must be able to handle competing priorities. * Ability for critical thinking and communication is required. * Strong interpersonal skills using clear, concise and professional verbal and written communication skills mandatory, mature judgment, and diplomacy required to interact effectively with a broad spectrum of people, both individually and in groups. * Ability to prioritize daily work tasks. * Ability to exercise initiative and judgment and make decisions within the scope of assigned authority. * Ability to identify sources of problems and arrive at appropriate solutions. * Understanding of complex systems and how they integrate and impact the entire organization. * Experience in defining problems, collecting data, establishing facts, and drawing valid conclusions. SALARY RANGE: $110,094.40- $165,131.20 ANNUALLY The Alliance is an equal opportunity employer and makes all employment decisions on the basis of merit and business necessity. We strive to have the best-qualified person in every job. The Alliance prohibits unlawful discrimination against any employee or applicant for employment based on race, color, religious creed, sex, gender, transgender status, age, sexual orientation, national origin, ethnicity, citizenship, ancestry, religion, marital status, familial status, status as a victim of domestic violence, assault or stalking, military service/veteran status, physical or mental disability, genetic information, medical condition, employees requesting accommodation of a disability or religious belief, political affiliation or activities, or any other status protected by federal, state, or local laws.
$110.1k-165.1k yearly 9d ago
Community Based Services Specialist
Santa Clara Family Health Plan 4.2
San Jose, CA job
Salary Range: $74,557 - $111,835 The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change. FLSA Status:Non-exempt Department:Community Based Programs Reports To:Manager, SDOH or Manager, Community Based Case Management Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521 GENERAL DESCRIPTION OF POSITION The Community Based Services Specialist serves as the lead, primary contact, and liaison for developing, supporting and monitoring the network of public and community based providers and vendors delivering Enhanced Care Management (ECM), Community Supports (CS), and/or other activities, programs or special projects addressing social determinants of health. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Develop and maintain updated knowledge of community based services, and capacity across Santa Clara County and support identification and assessment of ECM and/or CS provider network gaps. Recommend for initial and ongoing needs to support ECM and/or CS delivery system and operational infrastructure including data exchange, workforce training and capacity building. Support ECM and/or CS authorization and delivery process in accordance with DHCS-developed service definitions, eligibility criteria and reporting requirements. Oversee the development and management of the ECM, SDOH and/or CS provider network including: Serve as a knowledge and resource expert for ECM, CS and/or SDOH provider network operations. Establish and manage positive and productive working relationships with all public and community-based providers and vendors delivering services to members under ECM, CS or SDOH projects. Receive, research and respond to inquiries and issues that are raised by or impacting providers in a timely fashion and in collaboration with appropriate business units. Proactively communicate and collaborate with providers to identify problem patterns, track and trend issues, prepare recommendations for potential service improvement opportunities and develop tools and processes to improve communication and other processes Oversee collaboration with internal business units, particularly Provider Network Operations, Health Services Department, Finance and Claims, regarding provider communication, training and support and to ensure payments are made in accordance with vendor agreement terms. Schedule, conduct and report on regular site visits with each provider as required and coordinate and host at least one annual meeting with providers. Conduct orientation and ongoing training and education to community service providers and office staff including technical assistance, development of presentations and other written guidance or materials, in-person sessions, webinars and/or calls as needed. Assist in the preparation of promotional materials for the public, website or newsletters. Oversee provider compliance with required ECM and/or CS trainings and technical assistance including in-person sessions, webinars, and/or calls as necessary. Establish and oversee a program for communicating and tracking ECM and/or CS provider compliance with vendor agreement scope of work, key operational and financial objectives, and quality and performance metrics. Maintain accurate and timely documentation of provider contacts in compliance with NCQA standards, DHCS, DMHC and CMS regulatory requirements. Contribute to the development of ECM and/or CS pricing including recommending changes in pricing subsystems. Support the Department Manager in generating reports and performing special projects. Troubleshoot with providers to address issues related to submission of claims and encounter data for ECM and/or CS services. Understand and track applicable regulatory and reporting requirements. Ensure accuracy and regulatory compliance for all materials or documents. Attend off-site meeting or events as necessary. Perform other related duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. Bachelor's Degree in public health, social welfare or related field; or equivalent experience, training, or coursework. (R) Minimum two years of progressively responsible and direct work experience working with the essential duties and responsibilities described above. (R) Demonstrated experience leading/managing projects, initiatives, and/or leading or directing the work of others. (R) Knowledgeable in the field of home and community-based services and community resource networks and a particular interest in working to address health disparities and addressing the needs of low-income communities. A deep understanding of SDOH that impact Santa Clara County and community members. (R) Ability to think creatively and work strategically, to help develop and implement innovative solutions yielding measurable results to the organization. (R) Ability to think creatively and strategically, gather and analyze data, organize and write reports, organize work efficiently. (R) Ability to understand, interpret, and apply applicable rules and regulations, and establish and evaluate priorities. (R) Advanced working knowledge and proficient with Microsoft Suite applications, and the ability to operate all applicable software. (R) Excellent oral and written communication skills, including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments and outside entities over the telephone, in person or in writing.(R) Ability to effectively facilitate meetings and deliver information/presentations to management, regulators, or staff (R). Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) Ability to take initiative and exercise good judgment when making decisions within the scope of the position. (R) Ability to comply with all SCFHP policies and procedures. (R) Ability to perform the job safely with respect to others, to property, and to individual safety. (R) Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R) Knowledge of the community-based delivery system and managed care. (D) Project Management Professional (PMP) certification (D) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to regular contact with co-workers, managers, external partners, and vendors, in person, by telephone, and via work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) Reasoning Requirements:ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person, by telephone, and electronically, throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels. EOE (function () { 'use strict'; social Share.init(); })();
$74.6k-111.8k yearly 2d ago
Graphic Design Project Manager
Santa Clara Family Health Plan 4.2
San Jose, CA job
Salary Range: $98,601 - $147,902 The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change. FLSA Status: Exempt Department: Marketing & Communications Reports To: Manager, Marketing Production GENERAL DESCRIPTION OF POSITION The Graphic Design Project Manager develops, manages, and implements SCFHP's brand in all print and digital communications and manages website development in support of departmental and organizational objectives and in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Manage graphic design from inception to fulfillment in support of marketing and communications objectives and regulatory requirements, working with both internal and external stakeholders, as required. Develop new materials (hard copy or electronic) and update existing materials as needed to support programs, projects, and events. Develop the organization's brand and maintain its integrity in all materials. Develop and maintain effective systems to track all graphic design pieces, associated costs, and related expenses; analyze data to determine effectiveness and prepare marketing reports for management review. Identify, evaluate, and manage vendors to achieve Departmental objectives. Manage selection, ordering, design and proof approval of all marketing collateral, displays, and giveaway items. Manage website development to maintain and improve user experience and accessibility, and maintain brand experience across all digital platforms, working with internal stakeholders and external vendors. Develop, maintain, and use policies and procedures, operating instructions and tools needed to support marketing and communications activities. Analyze and track compliance with applicable regulatory and reporting requirements; monitor new requirements and update required documents accordingly. Attend and actively participate in department meetings, trainings, and coaching sessions. Identify issues, trends, and opportunities to improve efficiency and/or quality, or to better assist departments; develop recommendations and implement same relative to identified issues, trends, and opportunities. Attend offsite meetings or events as necessary. Perform other related duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. Bachelor's Degree in Marketing, Communications or related field, or equivalent experience. (R) Minimum three years of experience in graphic design and web development. (R) Minimum one year of experience in project management. (R) Ability to establish and maintain effective internal and external working relationships to organize and lead cross-functional teams. (R) Strong computer skills including fluency in Microsoft Word, Excel, PowerPoint, Adobe Acrobat, and Adobe Creative Suite; experience writing and managing complex documents including use of styles, bookmarks, and other document setup/management tools; and use of the Web for research. (R) Knowledge of Content Management System/HTML used for editing and maintaining website. (R) Very strong oral and written communication skills, with the ability to communicate data and information professionally, effectively, persuasively and on a timely basis to diverse individuals and groups inside and outside of the organization. (R) Ability to understand, interpret and communicate complex processes and abstract concepts for a variety of audiences. (R) Ability to think creatively and work strategically. (R) Ability to gather and analyze data, organize and write reports, and organize work efficiently. (R) Ability to produce accurate and precise work, detect discrepancies and resolve discrepancies all while meeting deadlines. (R) Ability to understand, interpret, and apply applicable rules, regulations, and establish and evaluate priorities. (R) Self-directed with proven ability to assume responsibility, work independently, meet deadlines, prioritize, and move projects to completion with minimum supervision. (R) Ability to take initiative and exercise good judgment when making decisions within the scope of the position. (R) Ability to think and work effectively under pressure. (R) Ability to maintain confidentiality. (R) Ability to comply with all SCFHP policies and procedures. (R) Ability to perform the job safely and with respect to others, to property, and to individual safety. (R) Fluent in written Spanish, Vietnamese, and/or Chinese. (D) Knowledge of healthcare, Medi-Cal managed care, and Medicare programs. (D) Project Management Professional (PMP) certification. (D) PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 20 pounds; (R) Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels. EOE (function () { 'use strict'; social Share.init(); })();
$98.6k-147.9k yearly 6d ago
Temp Grievance and Appeals Coordinator
Santa Clara Family Health Plan 4.2
San Jose, CA job
Salary Range: $66,273 - $99,409 The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change. FLSA Status:Non-Exempt Department:Grievance and Appeals Reports To:Supervisor, Grievance and Appeals GENERAL DESCRIPTION OF POSITION The Grievance and Appeals Coordinator is responsible for the beginning-to-end process of receiving, researching and resolving of new and existing member and provider grievance and appeals cases for all lines-of-business including any escalated step of the grievance and appeals process in accordance with state and federal regulatory requirements and SCFHP policies and procedures as set forth for each line of business. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. Act as a back-up to the Grievance and Appeals Intake Specialist during times of high volume work and/or staffing shortages to ensure appropriate intake of new and existing grievance and appeal cases, assessing the priority of each case and routing to the appropriate staff. Ensure grievance and appeals cases are accurate and include the necessary elements for processing and resolving, giving special attention to those identified as "Expedite". Create clear and concise documentation in applicable system(s). Use good judgment and department resources to identify all issues and required actions within a case, appropriately categorize cases and identify required actions in accordance with state and federal regulations. Produce and manage outbound documents, correspondence and reports in a manner that meets required timeframes. Ensure adherence with state and federal regulatory timeframes for handling cases including acknowledging cases, resolving cases, monitoring effectuation of resolution, completing resolution letters and communicating with members and providers within required timeframes. Prepare case files for State Fair Hearings, Independent Review Entities or other escalated types of cases, including documentation of the Statement of Position and case narratives. Represent SCFHP in any hearing proceedings. Develop effective and professional working relationships with internal and external stakeholders and partners. Communicate effectively with members and providers orally and in writing. Contact members and providers to seek additional information or clarification regarding grievance and appeals cases and review and resolve issues by requesting medical records, notice of action, or any other pertinent information related to grievances and appeals from medical groups, delegated entities and/or providers. Perform complete, accurate and consistent data entry into system software applications in accordance with policies, procedures and instruction from the Manager of Grievance and Appeals Operations. Maintain case files by ensuring that they are documented in accordance with state and federal requirements and organized in a manner that adheres to SCFHP standards and audit requirements. Participate in retrospective audit and review of cases and complete and correct gaps or errors in data. Identify operational issues and trends with SCFHP, delegates and other external stakeholders. Communicate these issues internally and externally and assist in formulating appropriate remediation plans. Assist the Manager of Grievance and Appeals Operations and peers with special projects. Work collaboratively and cross-functionally with other departments to facilitate appropriate resolutions. Work as a team to complete departmental tasks to meet deadlines and accomplish department objectives. Attend and actively participate in Grievance and Appeals Committee meetings, operational meetings and department meetings, trainings and coaching sessions. Perform other related duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. High School diploma or GED. (R) Associate's degree or equivalent experience, training or coursework. (D) Minimum two years of experience in customer service, provider service, health service, or pharmacy in a managed care or health care environment handling escalated or complex issues. (R) Knowledge of health plan benefits, processes and operations. (R) Prior experience with commercial, Medi-Cal and/or Medicare programs and working with the underserved populations. (R) Work weekends and company holidays as needed based on business regulatory requirements. (R) Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills. (D) Detail-oriented with the ability to conduct research and identify steps required to resolve issues and follow through to effectuation.(R) Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the Grievance and Appeals Department operations as dictated by business needs (R) Ability to consistently meet grievance and appeals accuracy and timeline requirements by achieving regulatory standards. (R) Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word and Excel. (R) Ability to use keyboard with moderate speed and a high level of accuracy. (R) Excellent communications skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, Members, Providers and outside entities over the telephone, in person or in writing. The ability to remain calm and de-escalate tense situations. (R) Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) Ability to maintain confidentiality. (R) Ability to comply with all SCFHP policies and procedures. (R) Ability to perform the job safely with respect to others, to property and to individual safety. (R) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment; (R) Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office and call center conditions. May be exposed to moderate noise levels. EOE (function () { 'use strict'; social Share.init(); })();
$66.3k-99.4k yearly 6d ago
Temp Manager, Utilization Management
Santa Clara Family Health Plan 4.2
San Jose, CA job
Salary Range: $130,622 - $202,465 The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change. FLSA Status:Exempt Department:Health Services Reports To:Director of Medical Management GENERAL DESCRIPTION OF POSITION The Manager of Utilization Management (UM) is responsible for the direct oversight of internal and external delegated UM functions including the development and implementation of policies, procedures and program development and related quality monitoring. In addition, the Manager of UM is responsible for supervising the Supervisor of UM to ensure that all administrative UM processes are performed in accordance with all applicable state and federal regulatory requirements, SCFHP policies and procedures and business requirements. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Develop, implement and manage all UM processes for continuous and sustained compliance with all applicable state, federal and NCQA regulatory requirements, SCFHP policies and procedures and general business requirements for all lines of business. Develop and implement continuous analysis and quality monitoring of all policies and procedures to evaluate UM staff performance and ensure regulatory compliance, including the development and implementation of effective, measurable corrective action plans to meet targeted strategic outcomes. Ensure the integration of UM operations into other internal and external teams/departments including Quality, Long Term Services and Support (LTSS) and Behavioral Health (BH). Establish and maintain effective interpersonal relationships with all SCFHP staff, members and/or their authorized representatives, providers and other program or agency representatives. Ensure UM Committee preparedness. Attend off-site meetings. Perform other related duties as required or assigned. SUPERVISORY/MANAGEMENT RESPONSIBILITIES Carries out supervisory/management responsibilities in accordance with the organization's policies, procedures, applicable regulations and laws. Responsibilities include: Recruiting, interviewing, and hiring. Developing a high performing department culture and staff. This includes setting the standard for staff/peers and motivating employees to maximize organizational goals and objectives. Effectively assimilating, training and mentoring staff and (when appropriate), cross training existing staff and initiating retraining. This includes coaching to help increase skills, knowledge and (if applicable) improve performance. Setting goals and planning, assigning, and directing work consistent with said goals. This includes responding to employees' needs, ensuring they have the necessary resources to do their work. Appraising performance, rewarding and disciplining employees, addressing complaints and resolving issues. This includes providing regular and effective feedback to employees and completing timely and objective performance reviews. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. Unrestricted professional RN licensure in the state of California. (R) Minimum two years of experience in a supervisory capacity in a managed care setting. (R) Understanding and/or experience with Utilization Management. (R) Must be knowledgeable of DHCS, CMS, DMHC regulations and NCQA regulatory Population Health standards. (R) Ability to consistently meet accuracy and timeline requirements to maintain regulatory requirements. Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case management programs. (R) Ability to use a keyboard with moderate speed and high level of accuracy. (R) Excellent written, verbal, and interpersonal communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing. (R) Ability to comply with all SCFHP policies and procedures. (R) Ability to think and work under pressure and effectively prioritize and complete tasks within established timeframes. (R) Ability to assume responsibility and exercise sound judgment when making decisions within the scope of this position. (R) Maintenance of a valid California Driver's License and acceptable driving record in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R) PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels. Frequent computer screen exposure. EOE (function () { 'use strict'; social Share.init(); })();
$130.6k-202.5k yearly 2d ago
Claims Analyst II
Santaclara Family Health Plan 4.2
San Jose, CA job
FLSA Status: Non-Exempt Department: Claims Reports To: Supervisor or Manager of Claims Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521. The Claims Analyst II analyzes, processes and adjusts routine and complex facility and professional claims for payment or denial to support the Claims Department operations in a manner that maintains compliance within the Medicare and Medi-Cal regulatory requirements and achieves Claims service-level objectives. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. 1. Follow established Health Plan policies and procedures and use available resources such as provider contracts, Medicare and/or Medi-Cal guidelines and Member Evidence of Coverage (EOC) to analyze, process and adjust routine and complex assigned claims in an accurate and timely manner. 2. Research, identify, resolve and respond to inquiries from internal Health Plan departments regarding outstanding claims-related issues. 3. Assist Claims Supervisor and Manager with pre-check run reports. 4. Maintain and organize all processes related to Third Party Liability (TPL) claims, including communication of relevant information to appropriate parties. 5. Participate in system testing and communicate newly-identified and potential issues to the Claims Supervisor and Manager and provide recommendations for improvement. 6. Process claims refund checks on a weekly basis to ensure accuracy/completeness of information and submit to the Finance Department in a timely manner. 7. Attend and actively participate in daily, weekly, and monthly departmental meetings, training and coaching sessions. 8. Perform other related duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. 1. High School Diploma or GED. (R) 2. Minimum two years of claims processing experience in a Health Plan Claims Department. (R) 3. Prior experience with managed care plans, Medi-Cal and/or Medicare programs, and working with underserved populations. (R) 4. Ability to analyze, process and adjust routine and complex assigned claims in an accurate and timely manner. (R) 5. Understanding of professional and hospital reimbursement methodologies, including medical terminology, and working knowledge of CPT, HCPCS, ICD-10, and ICD 9 codes. (R) 6. Understanding of the relationship between the health plans, IPAs, and DOFR. (R) 7. Ability to consistently meet Quality and Productivity Key Performance Indicators by participating in and achieving the Claims Quality standards. (R) 8. Ability to consistently meet Attendance Key Performance Indicator by being punctual and meeting the Claims standards in accordance with the team schedule. (R) 9. Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word and Excel. (R) 10. Ability to use a keyboard with moderate speed and a high level of accuracy. (R) 11. Working knowledge of QNXT claims processing software. (D) 12. Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers and outside entities over the telephone, in person or in writing. (R) 13. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) 14. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) 15. Ability to maintain confidentiality. (R) 16. Ability to comply with SCFHP's policies and procedures. (R) 17. Ability to perform the job safely with respect to others, to property, and to individual safety. (R) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: 1. Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) 2. Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) 3. Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) 4. Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) 5. Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) 6. Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels.
$79k-106k yearly est. 60d+ ago
Temp Medical Management Care Coordinator I
Santa Clara Family Health Plan 4.2
San Jose, CA job
Salary Range: $54,647 - $79,237 The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change. FLSA Status:Non-Exempt Department:Health Services Reports To:Supervisor, Utilization Management GENERAL DESCRIPTION OF POSITION The Medical Management Care Coordinator I performs non-clinical supportive duties related to utilization management (UM) and care coordination for Santa Clara Family Health Plan (SCFHP) members. Routine supportive duties include but are not limited to data entry into system software applications, managing department telephone queues, and assisting with quality monitoring projects for both SCFHP lines of business in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, Care Coordinator Guidelines and business requirements. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Follow established Health Services policies and procedures and use available resources to respond to member and/or provider inquiries and resolve any concerns in an accurate, timely, respectful, professional and culturally competent manner Collaborate with team members on improvement efforts across-departments regarding quality improvement projects, optimization of utilization management, and member satisfaction. Develop effective and professional working relationships with internal and external stakeholders and partners. Communicate effectively with members and providers orally and in writing. Assist in gathering and processing data for internal required reports and analysis. Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions. Follow UM policies and processes to the management of incoming authorization requests received through fax, mail or telephone. Identify authorization requests for line-of-business, urgency level, type of service, and assess for complete/incomplete record submission. Perform complete, accurate, and consistent data entry into system software applications in accordance with policies, procedures and instruction from UM management. Answer inbound UM phone queue calls timely to assist members and/or providers regarding inquiries involving authorizations, SCFHP program services, and/or benefits. Process written and verbal notifications of authorization determinations to members and/or providers within regulatory processing timeframes. Perform other duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. High school diploma or GED. (R) Minimum two years of experience in a health care setting in positions requiring interaction with members and/or providers. (R) Knowledge of health plan benefits, process and operations related to commercial, Medi-Cal and/or Medicare programs. (D) Proficient in adapting to changing situations and efficiently alternating focus between telephone and non-telephone tasks to support department operations as dictated by business needs. (R) Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R) Demonstrated ability to consistently meet Key Performance Indicators by participating in and achieving the standards put forth to achieve the standard requirements of the Utilization Management Department (R) Ability to work within an interdisciplinary team structure. (R) Work weekends and company holidays as needed based on business and regulatory requirements. (R) Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific UM programs. (R) Ability to use a keyboard with moderate speed and a high level of accuracy. (R) Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing. (R) Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) Ability to maintain confidentiality. (R) Ability to comply with all SCFHP policies and procedures. (R) Ability to perform the job safely and with respect to others, to property and to individual safety. (R) WORKING CONDITIONS Duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels. EOE (function () { 'use strict'; social Share.init(); })();
$54.6k-79.2k yearly 3d ago
Health Navigator
Santa Clara Family Health Plan 4.2
San Jose, CA job
Salary Range: $60,111 - $87,161 The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change. FLSA Status: Non-exempt Department: Health Services - Community-Based Programs Reports To: Manager, Social Determinants of Health Employee Unit:Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521 GENERAL DESCRIPTION OF POSITION The Health Navigator is responsible for providing on-going care coordination services for both Santa Clara Family Health Plan (SCFHP) members and other residents at designated supportive housing sites. Under the direction of the Manager, Social Determinants of Health, the Health Navigator will be proactive and responsive to members and residents 'needs in a friendly and professional manner. The Health Navigator provides health navigation support to help coordinate resources and services and support safety and housing retention for individuals at designated housing locations. The Health Navigator will work in close collaboration with housing staff and participants of the member/resident's care team to ensure needed services are provided. The Health Navigator will also act as a liaison to SCFHP and its providers to solicit participation in case management, community-based programs, and primary care services. The applicant must be a proactive team player who is also able to work independently in assigned communities and build rapport with diverse members, residents, providers and local partner agencies. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. Provide on-site and in-person orientation and health navigation services for SCFHP members and other residents/clients in collaboration with housing provider on-site staff and other members of the care team as appropriate. Educate member on managed care and how to navigate and access the health care system, benefits, and services including (but not limited to): health education, case management, behavioral health, primary care, vision, nurse advice line, enhanced care management, community supports, and appropriate use of the emergency department. Coordinate client's care with primary care providers, specialists, behavioral health providers, Long Term Services and Supports providers, public services, community providers, and vendors as necessary and appropriate to assist member to achieve and maintain optimal level of functional independence to reside in the most appropriate level of care. Conduct, review, and document comprehensive needs assessments and share with other care team members as necessary Provide guidance, education and referrals to help clients seek solutions to specific social, cultural, or financial problems that impact their ability to manage their health care needs and retain housing. Provides communication support and acts as Member advocate on issues of access and use of primary care and prevention services. Conduct in-person interviews and ongoing interactions with residents/members to assist in gathering information on their self-care ability, knowledge and adherence and challenges or risks related to housing retention. Establish ongoing primary care or achieve other improvements in health related activities. Maintain case files by ensuring that they are documented timely in accordance with SCFHP policies and procedures, state and federal requirements and organized in a manner that adheres to standards for audit requirements. Ensure the privacy and security of PHI (Protected Health Information). Share related information about client's physical and mental health conditions to client's interdisciplinary care team Maintain knowledge of current resources in Santa Clara County to support care coordination Develop effective and professional working relationships with internal and external stakeholders and partners. Identify issues and trends (data, systems, member or provider or other) as well as general departmental questions/concerns and report relevant information to management and make recommendations to improve operation Collaborate with SCFHP team members on cross-departmental improvement efforts, organizational and departmental objectives, quality improvement projects, optimization of utilization management, and improvement of member satisfaction. Attend and actively participate in Health Services meetings, operational meetings, training and coaching sessions, including off-site meetings as needed. Perform other duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. High School diploma (R) Bachelor's Degree in a health-related or social services field or equivalent experience, training or coursework (D) Minimum two years of experience in Community Outreach or case coordination. (R) Knowledge of social case management and conflict resolution. (D) Knowledge of long-term services and supports, behavioral health and/or relevant public services and community resources. (R) Strong organization and time-management skills (R) Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R) Vietnamese, Chinese, Tagalog or Spanish language bi-lingual skills. (D) Experience working with designated member population (e.g. behavioral health, seniors and persons with disabilities). (D) Ability to work within an interdisciplinary team structure. (R) Travel to off-site locations for work such as in office, housing site, facility, clinic, and other community settings. (R) Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R) Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the operations as dictated by business needs. (R) Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case management programs. (R) Ability to use a keyboard with moderate speed and a high level of accuracy. (R) Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing as mandated by social work scope of practice. (R) Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) Ability to maintain confidentiality. (R) Ability to comply with all SCFHP policies and procedures. (R) Ability to perform the job safely and with respect to others, to property and to individual safety. (R) WORKING CONDITIONS Generally, duties are primarily performed in an off-site housing environment . Incumbents are subject to frequent contact with clients, housing co-workers, and plan members or providers in person, by telephone, and by work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels. EOE (function () { 'use strict'; social Share.init(); })();
$60.1k-87.2k yearly 2d ago
Manager, Application Development
Santa Clara Family Health Plan 4.2
San Jose, CA job
Salary Range: $153,481 - $237,896 The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change. FLSA Status: Exempt Department: Information Technology Reports To: Director, Application and Product Development GENERAL DESCRIPTION OF POSITION The Manager of Application Development is responsible for the supervision of the application development staff in the design, development, implementation and support of in-house and vendor applications and interfaces, including the accurate data exchange between trading partners in accordance with state and federal regulatory and contractual requirements and SCFHP policies and procedures as set forth for all lines of business. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. Supervise and mentor personnel performing design, development, implementation, maintenance, and reporting from application databases, data warehouse and data cube environments. Oversee the design, development, implementation, and maintenance of electronic data exchange in multiple formats, including EDI X 12 transaction sets specific to healthcare transactions. Oversee the development and maintenance of enterprise data warehouse. Exercise staff oversight to ensure new operations plans, policies, procedures and transition/migration plans are consistent with the overall company goals and objectives. Define and modify IT development standards, policies and procedures to ensure they remain current with business and regulatory needs. Participate in the project approval and prioritization process with other IT management and business leaders. Contribute and participate in the strategic planning process and share in the development of SCFHP vision, goals and initiatives. Develop positive relationships with managers, directors and leaders by understanding business priorities and information technology enablers. Perform other related duties as required or assigned. SUPERVISORY/MANAGEMENT RESPONSBILITIES Carries out supervisory/management responsibilities in accordance with SCFHP's policies, procedures, applicable regulations and laws. Responsibilities include: Recruiting, interviewing, and hiring. Developing a high performing department culture and staff. This includes setting the standard for staff/peers and motivating employees to maximize organizational goals and objectives. Effectively assimilating, training and mentoring staff and (when appropriate), cross training existing staff and initiating retraining. This includes coaching to help increase skills, knowledge and (if applicable) improve performance. Setting goals and planning, assigning, and directing work consistent with said goals. This includes responding to employees' needs, ensuring they have the necessary resources to do their work. Appraising performance, rewarding and disciplining employees, addressing complaints and resolving issues. This includes providing regular and effective feedback to employees and completing timely and objective performance reviews. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. Bachelor's Degree in Business Administration, Computer Science, Public Health, or related field, or equivalent training/experience. (R) Minimum five years of experience in a lead or supervisory capacity. (R) Minimum ten years of experience in application development. (R) Minimum ten years of experience, with SQL programming, MS SQL database development, and T-SQL query generation. (R) Minimum five years of experience with MS SQL Business Intelligence tools (SSRS, SSIS, SSAS) or other enterprise business intelligence software. (R) Minimum five years of programming background in any of the following applicable languages/platforms; .NET, PERL, Java, SAS, VB, C++, C#, or other modern programming language or related software. (R) Demonstrated knowledge of software development life cycle (SDLC), coding standardization, peer review and user acceptance testing. (R) The ability to effectively manage multiple projects across multiple team members, including direct reports and other IT staff members. (R) Excellent data analysis skills. (R) Knowledge of and experience with healthcare management information systems. (R) Good working knowledge of BizTalk, Sharepoint, ActiveBatch and other core integration tools and services. (D) Working knowledge of and the ability to efficiently operate all applicable computer software including a working knowledge of computer applications such as Outlook, Word and Excel. (R) Ability to use a keyboard with moderate speed and a high level of accuracy. (R) Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers and outside entities over the telephone, in person or in writing. (R) Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) Ability to maintain confidentiality. (R) Ability to comply with SCFHP's policies and procedures. (R) Ability to perform the job safely with respect to others, to property, and to individual safety. (R) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to regular contact with co-workers, managers, external partners, and vendors in person, by telephone and via work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels. EOE (function () { 'use strict'; social Share.init(); })();
$153.5k-237.9k yearly 5d ago
Lead Investigator, Special Investigative Unit-(Kentucky)
Molina Healthcare 4.4
Long Beach, CA job
Under direct supervision of the Manager, SIU, the Team Lead is responsible to lead a small team of investigators and provide oversight on daily investigative activities as a back-up to the SIU Manager. This position will be accountable for tracking on investigations conducted by his/her team and will provide oversight and guidance throughout the life of an investigation as well as QA reviews and approvals. In addition to leading a team of investigators and analysts, the Team Lead will ensure the Manager is aware of any major case developments, and ensure cases are being investigated according to the SIU's standards. Position must have thorough knowledge of Medicaid/Medicare/Marketplace health coverage audit policies and be able to apply them in ensuring program compliance via payment integrity programs. The position must have the ability to determine correct coding, documentation, potential fraud, abuse, and over utilization by providers and recipients. The position will review claims data, medical records, and billing data from all types of healthcare providers that bill Medicaid/Medicare/Marketplace. KNOWLEDGE/SKILLS/ABILITIES Ensure investigators are managing their cases effectively and in accordance with SIU policies, processes, quality standards, and procedures. Ensure that investigators are managing their respective State Reporting requirements and assignments effectively and timely. Manage the flow of day-to-day investigations. Perform assessment that QA measures were complete and signed-off Provide guidance to investigators as needed on investigative techniques, tools, or strategy. Effectively investigate and manage complex and non-complex fraud allegations. Develop and maintain relationships with key business units within specific product line and geographic region. Provides direction, instructions, and guidance to Investigative team, particularly in the absence of the SIU Manager. Provide training to team members as needed. Communicate clear instructions to team members, listen to team members' feedback. Monitor team members' participation to ensure the training provided is effective, and if any additional training is needed. Create, edit, and update assigned reports to apprise the company on the team's progress. Distribute reports to the appropriate personnel. JOB QUALIFICATIONS Required Education High School/GED Associates degree or bachelor's degree in Health Information Management, Health Care Administration, Finance, Criminal Justice, Law Enforcement, or related field (applicable FWA experience would be accepted in lieu of education experience) Required Experience Associates degree or bachelor's degree in Health Information Management, Health Care Administration, Finance, Criminal Justice, Law Enforcement, or related field (applicable FWA experience would be accepted in lieu of education experience) At least five (5) years' experience working in a Managed Care Organization or health insurance company Minimum of three (3) years' experience working on healthcare fraud related investigations/reviews Proven investigatory skill; ability to organize, analyze, and effectively determine risk with corresponding solutions; ability to remain objective and separate facts from opinions Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations Knowledge of Managed Care and the Medicaid and Medicare programs as well as Marketplace Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems Understanding of datamining and use of data analytics to detect fraud, waste, and abuse Proven ability to research and interpret regulatory requirements Effective interpersonal skills and customer service focus; ability to interact with individuals at all levels Excellent oral and written communication skills; presentation skills with ability to create and deliver training, informational and other types of programs Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook), SharePoint and Intra/Internet as well as proficiency with incorporating/merging documents from various applications Strong logical, analytical, critical thinking and problem-solving skills Initiative, excellent follow-through, persistence in locating and securing needed information Fundamental understanding of audits and corrective actions Ability to multi-task and operate effectively across geographic and functional boundaries Detail-oriented, self-motivated, able to meet tight deadlines Ability to develop realistic, motivating goals and objectives, track progress and adapt to changing priorities Energetic and forward thinking with high ethical standards and a professional image Collaborative and team-oriented Required License, Certification, Association Valid driver's license required. Preferred Experience Healthcare Anti-Fraud Associate (HCAFA), Accredited Health Care Fraud Examiner (AHFI) and/or Certified Fraud Examiner (CFE) preferred. To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. #PJCorp #LI-AC1
$50k-80k yearly est. Auto-Apply 60d+ ago
Senior Health Data Analyst I
Partnership Healthplan of California 4.3
Fairfield, CA job
The Senior Healthcare Data Analyst I contributes to the overall success of the organization by developing analytic solutions that support activities related to health services utilization management, care coordination, quality improvement and population health. Through analyzing patient claims, member enrollment, and other data, the Senior Healthcare Data Analyst participates in identifying progress, performance and opportunities for improvement on programs, quality of care, patient experience, and other metrics. This position requires a thorough understanding of healthcare data and workflows, combined with an extensive experience working with large data sets, conducting data analysis, including standard statistical software (SAS), and creating reports using Tableau. Responsibilities Works collaboratively with business partners, other analysts, and IT to gather and integrate data from disparate sources. Responds to ad hoc data requests from business units and leadership Assists in design and development of data collection strategies, aggregation, analysis, and reporting to ensure data integrity and enhance information value. Participates in design and interpretation of data analyses; provides recommendations for improvement of data quality and reporting. Helps build, manage, and/or enhance predictive models Assesses reporting and automation requirements and develops appropriate solutions. Maintains in-depth knowledge of health plan operations, including claims processing, utilization management, quality improvement activities and pay for performance programs. Critically analyzes data, draws conclusions and effectively articulates results. Presents data and conclusions to non-technical audience; uses data visualizations and summaries to highlight key findings. Creates and maintains thorough and consistent documentation of programs used to create reports. Manages and prioritizes workload while meeting deliverables and expectations. Works autonomously and collaboratively with report requestors, providing guidance to define report requirements and validate results. Works collaboratively across departments to understand and meet the organization's analytic needs. SECONDARY DUTIES AND RESPONSIBILITIES Performs other assigned or needed activities required to assure success of the organization. Participates in special projects as needed. Performs other duties as assigned. General Traits Passionate about data, willing to acquire new skills and knowledge, flexible, self-motivated, and very curious. Creative problem-solver, critical thinker, independent worker, data-driven mentality. Communicates clearly and directly, relates well to others, engages people, provides and seeks feedback, articulates clearly, actively listens. Qualifications Education and Experience Bachelor's degree with concentration in health informatics, health administration, public health, computing, epidemiology, statistics or related field, Master's degree preferred. Minimum four (4) years of experience in data analysis and reporting. Knowledge of major health plan operations: healthcare claims processing, membership, provider, and benefits; or equivalent combination of education and experience. Excellent knowledge of data collection, analysis, statistics and data presentation with experience in data mining techniques and procedures. Experience using statistical packages for analyzing large data sets, SAS and/or SQL a plus. Experience working with administrative data, ideally health care data (Medicaid data a plus). Understanding of health data formats including claims, lab and pharmacy. Knowledge of clinical coding systems (e.g., ICD9, ICD10, CPT). Special Skills, Licenses and Certifications Proficiency in inferential and predictive statistical analysis. MS Office, Excel, SQL, SAS, Tableau. Ability to present complex information in an understandable and compelling manner. Performance Based Competencies Ability to quickly acquire in-depth knowledge of various systems related to claims processing, membership, provider, and benefits at Partnership. Strong written and oral communication skills with ability to interpret and understand technical requirements. Excellent analytical skills to troubleshoot and resolve data issues. Must be highly organized and proficient at multi-tasking. Must be willing and able to provide gracious assistance to users, providers, and other constituents of Partnership. Work Environment And Physical Demands More than 50% of work time is spent at a video display terminal. All HealthPlan employees are expected to: Provide the highest possible level of service to clients; Promote teamwork and cooperative effort among employees; Maintain safe practices; and Abide by the HealthPlan's policies and procedures, as they may from time to time be updated. HIRING RANGE: $103,059.95 - $133,977.94 IMPORTANT DISCLAIMER NOTICE The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.
$103.1k-134k yearly Auto-Apply 42d ago
Medicare Outreach Agent (bilingual - Spanish)
Santaclara Family Health Plan 4.2
Gilroy, CA job
FLSA Status: Exempt Department: Marketing, Outreach and Enrollment Reports To: Manager, Medicare Outreach The Medicare Outreach Agent executes SCFHP's Medicare outreach and enrollment operations to grow SCFHP Medicare enrollment in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements, and in support of organizational objectives. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. * Execute sales and outreach strategy to maximize membership growth, including meeting Medicare enrollment goals as well as individual sales and performance goals. * Ensure timely follow-up on questions, issues and concerns from beneficiaries, members, providers, community partners. * Organize and conduct sales presentations in the community and assist eligible beneficiaries to enroll, including conducting a needs assessment to best explain product offerings. * Make outbound calls to follow up and close business; receive and manage inbound enrollment calls. * Manage and execute outreach plan to providers and community based organizations to support achievement of Medicare enrollment objectives. * Seek opportunities to improve SCFHP image/visibility in the community. Contribute ideas to increase retention and enrollment. * Develop, maintain and use competitive analysis to inform outreach and retention efforts, including identifying and studying key competitors and their products, as well as related industry issues to maintain a personal awareness of competitive advantages and disadvantages; share the competitive analysis with the Marketing and Outreach teams. * Stay current on SCFHP product and competing products; stay current on CMS Medicare Marketing Guidelines and with California specific Medicare-Medicaid Plans Medicare Marketing Guidelines. * Successfully complete SCFHP required product and certification training; maintain California Life, Accident and Health Insurance License. * Identify issues and trends (data, systems, beneficiary, member, provider, other) as well as general departmental questions/concerns and report relevant information to management; make recommendations. * Address member questions, concerns, grievances, appeals or requests for services in accordance with policies and procedures, including appropriate documentation and communication with other departments. * Assist with new hire training by having new hires shadow, observe in the community, and listen to calls, in accordance with training guidelines and protocols. Observe new hires and provide feedback to the Department Manager. * Attend and actively participate in daily, weekly, and monthly departmental meetings, training and coaching sessions. * Perform other related duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. * Associate's Degree in a related field of study, or equivalent training/experience. (R) * Minimum two years of Medicare sales, Medicare benefits advisory work, or Medi-Cal eligibility advisory work experience. (R) * Strong presentation skills with intent to sell. (R) * California Life, Accident and Health Insurance License, or the ability to obtain within 60 days of employment. (R) * Self-directed with proven ability to assume responsibility, work independently, meet deadlines and prioritize with minimum supervision. (R) * Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R) * Experience with, and understanding of, Medicare outreach and/or sales. (R) * Experience with managed care and Medi-Cal. (D) * Knowledge of current trends, practices, strategies, tools for outreach and sales, including customer relation management applications. (D) * Ability to establish and maintain effective working relationships with providers, community based organizations and program participants. (R) * Bilingual in Spanish, Vietnamese, Mandarin or Cantonese. (R) * Ability to work nights and/or weekends as needed. (R) * Working knowledge of and the ability to efficiently operate all applicable computer software including a working knowledge of computer applications such as Outlook, Word and Excel. (R) * Ability to use a keyboard with moderate speed and a high level of accuracy. (R) * Excellent communication skills including the ability to express oneself clearly and concisely when providing service to beneficiaries, SCFHP members, providers and outside entities in person, over the telephone, or in writing. (R) * Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) * Ability to take initiative and exercise good judgment when making decisions within the scope of the position. (R) * Ability to maintain confidentiality. (R) * Ability to comply with all SCFHP policies and procedures. (R) * Ability to perform the job safely with respect to others, to property, and to individual safety. (R) WORKING CONDITIONS Duties are performed away from the office in varied community settings, and also in an office environment while sitting or standing at a desk. Incumbent's responsibilities require frequent contact with beneficiaries, members and providers, as well as interaction with co-workers and managers, in person, by telephone, and via electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: * Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 20 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS Outside of the office - community settings, meeting rooms. In the office - general office conditions. May be exposed to moderate noise levels.
$40k-68k yearly est. 60d+ ago
Supervisor, Utilization Management (Clinical)
Santaclara Family Health Plan 4.2
San Jose, CA job
FLSA Status: Exempt Department: Health Services Reports To: Manager, Utilization Management The Supervisor of Utilization Management (UM) is responsible for the direct oversight of daily operations of utilization management activities, providing assistance with the development and implement of new programs and related workflows, policies, procedures for all lines of business, and serving as a resource for internal departments, members, providers, delegates, and community partners. In addition, the Supervisor of UM is responsible for supervising nurses and coordinators to ensure that all administrative UM processes are performed in accordance with all applicable state and federal regulatory requirements, SCFHP policies and procedures and business requirements. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. 1. Collaborate with the Manager of Utilization Management to implement and supervise all UM processes for continuous and sustained compliance with all applicable state, federal and NCQA regulatory requirements, SCFHP policies and procedures and general business requirements including key performance indicators of MCAS, HEDIS, and CMS Stars for all lines of business. 2. Monitor and provide continuous analysis and quality monitoring of all policies and procedures to evaluate UM staff and delegate performance and ensure regulatory compliance, including the development and implementation of effective, measurable corrective action plans to meet targeted strategic outcomes. 3. Ensure the integration of UM operations such as prior authorization, concurrent review, Transitional Care Services (TCS), and discharge planning into other internal and external teams/departments including Quality & Process Improvement, Case Management, Community Based Programs, Pharmacy, and Behavioral Health. 4. Perform oversight and assignment of caseload across various utilization management functions including routine and ad hoc audits and monitoring of corrective action plans. 5. Establish and maintain effective interpersonal relationships with all SCFHP staff, members and/or their authorized representatives, providers and other program or agency representatives. 6. Resolve or facilitate resolution of problematic and/or complex issues by escalating to appropriate management/leadership person. 7. Ensure Utilization Management Committee preparedness. 8. Attend off-site meetings, events, or facility census review as necessary. 9. Perform other related duties as required or assigned. SUPERVISORY/MANAGEMENT RESPONSBILITIES Carries out supervisory/management responsibilities in accordance with the organization's policies, procedures, applicable regulations and laws. Responsibilities include: 1. Recruiting, interviewing, and hiring. 2. Developing a high performing department culture and staff. This includes setting the standard for staff/peers and motivating employees to maximize organizational goals and objectives. 3. Effectively assimilating, training and mentoring staff and (when appropriate), cross training existing staff and initiating retraining. This includes coaching to help increase skills, knowledge and (if applicable) improve performance. 4. Setting goals and planning, assigning, and directing work consistent with said goals. This includes responding to employees' needs, ensuring they have the necessary resources to do their work. 5. Appraising performance, rewarding and disciplining employees, addressing complaints and resolving issues. This includes providing regular and effective feedback to employees and completing timely and objective performance reviews. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. * Unrestricted professional RN licensure in the state of California. (R) * Minimum two years of progressively responsible experience in a supervisory or lead capacity in case management, utilization management, discharge planning and/or quality improvement in a managed care related setting. (R) * Understanding and/or experience with Utilization Management. (R) * Must be knowledgeable of DHCS, CMS, DMHC regulations and NCQA Population Health Management standards. (R) * Ability to consistently meet accuracy and timeline requirements to maintain regulatory requirements. * Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case management programs. (R) * Ability to use a keyboard with moderate speed and high level of accuracy. (R) * Excellent written, verbal, and interpersonal communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing. (R) * Ability to comply with all SCFHP policies and procedures. (R) * Ability to think and work under pressure and effectively prioritize and complete tasks within established timeframes. (R) * Ability to assume responsibility and exercise sound judgment when making decisions within the scope of this position including performing job safely and within respect to others, to property and to individual safety (R) * Maintenance of a valid California Driver's License and acceptable driving record in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R) PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: * Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels.
$80k-110k yearly est. 60d+ ago
Manager of Quality Incentive Programs
Partnership Healthplan of California 4.3
Fairfield, CA job
The Manager of Quality Incentive Programs is responsible for managing Partnership HealthPlan's Primary Care, Hospital, and Long Term Care Quality Incentive Programs, also known as Quality Improvement Programs (QIPs). The QIPs provide financial incentives, data, and technical assistance to our provider network for meeting performance improvement targets. As part of this work, the position oversees Partnership's Provider Data Portal which allows providers to evaluate their performance and obtain data to manage their patients and ultimately improve care. Responsibilities Provides oversight, mentoring, and coaching to the QIP team in the following areas: Development and implementation of communication plans and presentations to Partnership's leadership and physician committees; Strategic leadership to all QIP programs including experience formulating objectives and priorities and implementing plans consistent with long term views/vision. Capitalizes on opportunities and effectively manages risks; Provides direction to the planning, implementation, and evaluation of all components for quality incentive programs; Provides advice and support on quality incentives programs run through other Partnership departments, such as, the pharmacy 340B QIP, the mental health QIP, and the specialty QAIP; In conjunction with the Partnership leadership team and community stakeholders, develops other pay for performance programs, as needed; Works collaboratively with IT and Health Analytics departments on the data systems to support regular measurement and feedback on the QIP measures; Researches and advises on program, payment, and incentive methodologies for quality incentive programs; Models data-driven leadership, ensuring interventions are measured and evaluated for efficacy and impact; Understands and exhibits expert knowledge in the various components of the QIPs. In conjunction with the Director of QI/PI and the CMO, oversees the development, implementation, and evaluation of the Provider Data Portal: Works with Partnership departments, business analysts, and providers to gather business requirements through observation, interviews, and facilitated questions; Works with business analysts, vendors, and IT department to develop prototypes for the portal; Oversees the testing, implementation, long-term management, and continuous improvement of the portal; Oversees the data integrity and reporting from the portal by ensuring data management and validation processes are in place; Provides direction to the team on all aspects of the portal. Leads a high performing team: Supports the development of the QIP and Provider Portal teams by establishing clear goals, expectations, and metrics to ensure that they are used to continually motivate staff and support meeting department goals and objectives; Hires, trains, coaches, supports, and directly supervises QIP staff. Regularly assesses staffing needs and advocates for additional staff as required. Serves as member of QI Department and Health Services Management Teams: Supports QI Department Director in budget management, staffing decisions, and strategic and operational planning; Collaborates with department director and QI management team to ensure alignment of efforts across the department. Helps develop and manage communication feedback loops so work from other areas (i.e. QIP programs, HEDIS, analytics, regional offices) informs QIP and Data Portal priorities, and vice versa; Collaborates extensively with QI staff in Redding office to foster alignment and cohesion across QIP, provider data portal, and other QI department functions; Attends Health Services Management Team meetings and stays informed of critical work across Health Services department. Advises of Health Services department strategy and continually assesses and adjusts operational plan of QIP team to support this larger strategy; Works with other directors and managers across the QI department and Partnership as a whole on data and measurement related activities, including the Quality Improvement Program, Partnership Stars Dashboard, provider reporting tools, and internal dashboards and program evaluations. Stays informed on key developments in the quality improvement field that impact our provider network, including patient-centered medical home certification criteria, meaningful use, primary care transformation best practices, and quality reporting requirements. Stays informed of key developments and research in the area of Pay for Performance. Assures that processes for Quality Improvement projects are HIPAA compliant and implements any needed changes or upgrades. Accepts other responsibilities as determined by the needs of the QI Department. Qualifications Education and Experience Bachelor's degree is required; Master's degree in healthcare is strongly preferred. At least four (4) years of experience in project management related to healthcare. Prior supervision of staff is required. Special Skills, Licenses and Certifications Advanced data analytic skills. Knowledge of healthcare quality data. Understanding of improvement measurement and analysis using run charts (trending data over time), and making decisions based on these data. Valid California driver's license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business. Performance Based Competencies Strong written and oral communication skills. Strong organization skills to work on multiple projects simultaneously within established time frames. Ability to plan, implement, and report on quality management projects. Strong analytic and critical thinking skills. Work Environment And Physical Demands More than 50% of work time is spent using a desktop computer. When necessary, the ability to lift, carry, or move manuals and reports, weighing up to 25 lbs. Must be able to work in a fast paced environment and maintain courtesy and composure when dealing with internal and external customers. Ability to function effectively with frequent interruptions and direction from multiple team members. All HealthPlan employees are expected to: Provide the highest possible level of service to clients; Promote teamwork and cooperative effort among employees; Maintain safe practices; and Abide by the HealthPlan's policies and procedures, as they may from time to time be updated. HIRING RANGE: $118,518.94 - $154,074.63 IMPORTANT DISCLAIMER NOTICE The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.
$118.5k-154.1k yearly Auto-Apply 13d ago
Systems Database Administrator
Santaclara Family Health Plan 4.2
San Jose, CA job
FLSA Status: Exempt Department: Information Technology Reports To: Director, Infrastructure and Systems Support Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521 The Systems Database Administrator is responsible for database security, integrity, performance, availability, and recoverability of databases, database servers, and related systems. In addition, the Systems Database Administrator is responsible for installing, configuring, and maintaining database servers, databases, related objects, and related software and for database security in support of SCFHP objectives and regulatory compliance. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. * Provide technical management and support for the organization's database environments to ensure database security, integrity, performance, availability and recoverability of databases, database servers, and related systems. * Develop, implement, and periodically test backup and recovery plan for the production of critical databases to ensure the business continuity plan is accurate and effective. * Ensure database security by controlling access to databases through authentication and authorization and performing auditing of database usage and active users. * Audit database security and user access to ensure HIPPA regulatory law reporting requirements are met. * Monitor database server resources to ensure production environments meet performance and availability requirements. * Install, test, secure and maintain new versions of database software, patches and other associated software application changes or upgrades. * Provide storage and capacity planning, long and short term, to ensure adequate space is available for all database environments. * Document database architecture, including developing and maintaining database installation and configuration procedures, data governance program, change control deployment procedures, and SQL coding guidelines. * Work with the application development team to ensure that appropriate and efficient SQL is coded and tested prior to production deployment. * Perform other related duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. * Bachelor's Degree in Computer Science, or related field, or equivalent experience, training or coursework. (R) * Minimum three years of experience serving as a systems database administrator in a Microsoft SQL Server environment with versions currently supported by Microsoft. (R) * Microsoft Certified Solutions Expert (MCSE). (D) * Minimum three years of experience maintaining multiple database environments and regions to support production, development and test areas of business systems; including managing database security, database tuning, query optimization, and application code deployment. (R) * Minimum three years of experience SQL Scripting and Command Shell scripting. (R) * Minimum three years of experience with any of the following applicable languages/platforms: .NET, PERL, Java, SAS, VB, C++, or other modern programming language or related software. (R) * Minimum three years of experience with MS SQL Business Intelligence tools (SSRS, SSIS, SSAS) or other enterprise business intelligence software. (R) * Experience maintaining a data warehouse database environment, including managing and enforcing data governance and coding best practice. (R) * Ability to create and maintain documentation of source code, application installation processes, technical specifications, and data governance program. (R) * Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word and Excel. (R) * Ability to use a keyboard with moderate speed and a high level of accuracy. (R) * Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers and outside entities over the telephone, in person or in writing. (R) * Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) * Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) * Ability to maintain confidentiality. (R) * Ability to comply with SCFHP's policies and procedures. (R) * Ability to perform the job safely with respect to others, to property, and to individual safety. (R) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: * Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels.
$104k-133k yearly est. 56d ago
Customer Service Representative I
Santaclara Family Health Plan 4.2
San Jose, CA job
FLSA Status: Non-Exempt Department: Customer Service Reports To: Supervisor, Customer Service The Customer Service Representative I answers inbound calls and makes outbound calls to support Customer Service Department operations in a manner that maintains compliance with Medicare and Medi-Cal regulatory requirements and achieves Call Center service-level objectives. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. * Act as the primary point of contact and liaison for SCFHP members and providers contacting the plan regarding general inquiries, concerns or requests for information. * Develop a general understanding of all member facing materials, communications and interactions and be prepared to respond appropriately to follow up calls. * Answer inbound calls and/or place outbound calls in a high call volume environment and work directly with members and providers to accurately and completely answer inquiries involving SCFHP program services and benefits. * Follow established guidelines and resources to respond to member and provider inquiries and resolve concerns in an accurate, timely, professional, and culturally competent manner. * Intake, handle and coordinate member grievances, appeals and billing issues, escalating to the Grievance and Appeals department, when necessary. * Educate members and providers on eligibility, and medical and pharmacy benefits and how to access services in a manner that achieves excellent service standards and maintains high customer satisfaction. * Use listening skills and judgment to appropriately categorize and accurately document all contacts and follow-up actions regarding member and provider communications and activities in accordance with established guidelines. * Appropriately handle member and provider requests through alternative channels such as e-mail, voicemail, fax, walk-in, etc. in accordance with established procedures. * Triage member and provider requests or inquiries for other departments. * Conduct member surveys as assigned in accordance with established guidelines. * Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions. * Identify member/provider issues and trends and report relevant information to management. * Perform other related duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. * High School Diploma or GED. (R) * Minimum one year of experience in Customer Service or Call Center role, preferably within a Health Care, Public Assistance or Human Services programs. (R) * Prior experience with managed care plans, Medi-Cal and Medicare programs, and working with underserved populations. (D) * Ability to meet Key Performance Indicators by participating in and achieving the standards of the Customer Service Call Center Quality Program. (R) * Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills. (D) * Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications, such as Outlook, Word and Excel. (R) * Ability to use a keyboard with moderate speed and a high level of accuracy. (R) * Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP Plan members and providers over the telephone, in person or in writing. (R) * Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) * Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) * Ability to maintain confidentiality. (R) * Ability to comply with all SCFHP policies and procedures. (R) * Ability to perform the job safely with respect to others, to property, and to individual safety. (R) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: * Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels.
$34k-42k yearly est. 60d+ ago
Health Services Analyst I
Partnership Healthplan of California 4.3
Santa Rosa, CA job
Perform routine and ad-hoc reporting and data management for internal and external users; assist in maintaining reporting systems within the department. To prepare, analyze, report, and manage data used for both plan-wide and regional decision making for evaluating performance in key quality measures and the effective use of health plan resources on a routine and ad hoc basis. Works collaboratively with departments company-wide to identify data needs, develop and maintain data queries and tools, and complete accurate reporting to support performance and process improvements. Responsibilities Develops and maintains working knowledge (technical and user interfaces) of Partnership data management and analytics programs and systems. May manage/monitor data integration into data infrastructure and may lead system-level user testing. Utilizes the Enterprise Data Warehouse and other data sources to identify and isolate data for analysis. Validates data reports and manages key data sources within program requirements, to ensure the completeness and accuracy of data. Works collaboratively with various departments (i.e. QI, IT, Finance, and Analytics teams) and external stakeholders to define business requirements and identify data needs. Refines reporting requests to support operational excellence initiatives and creates tools and reports to measure process/performance changes. Develops and executes data collection plans that identify baseline performance and capture the impact of interventions. Analyzes performance data (which may include data trending or stratification) to identify areas for improvement. Provides actionable recommendations and informs stakeholders of the impact of key decisions based on available data. Serves as active contributor in data quality or analytics workgroups. Develops and maintains standards and methodologies in data governance and data quality issue resolution timelines; streamlines reporting to reduce unnecessary duplication; ensures consistent and accurate use of data reporting; and provides accurate definitions of all data elements. Serves as a primary contact for internal and external stakeholders related to Partnership performance data management. Prepares and validates DHCS and/or NCQA reports for Health Services Serves as the analytic lead on select operational initiatives as assigned. Maintains expert knowledge of assigned business unit. Provides project management support for data related and performance/process improvement projects. Tracks multiple deliverables and collaborates closely with broader project team. Other duties as assigned. Qualifications Education and Experience Bachelor's degree in related field; one - two (1-2) years of experience providing the knowledge and abilities listed. Special Skills, Licenses and Certifications Demonstrated aptitude for acquiring and applying technical skills in data analysis, reporting, and data systems. Good oral and written communication skills. Strong analytical skills including knowledge of statistics. Excellent interpersonal skills. Valid California driver's license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business. Performance Based Competencies Knowledge of MS Excel, Access, and other analytic software. Knowledge of Lean and Model for Improvement methodologies. Familiar with quality measurement and healthcare data. Ability to communicate technical concepts with both technical and non-technical individuals. Detail-oriented with good organizational and project management skills to work on multiple projects simultaneously within established time frames. Work Environment And Physical Demands Ability to use a PC with standard software packages. More than 70% of work time is spent in front of a computer monitor. When required, ability to move, carry, or list objects of varying size, weighing up to 25 lbs. All HealthPlan employees are expected to: Provide the highest possible level of service to clients; Promote teamwork and cooperative effort among employees; Maintain safe practices; and Abide by the HealthPlan's policies and procedures, as they may from time to time be updated. HIRING RANGE: $77,430.47 - $96,788.08 IMPORTANT DISCLAIMER NOTICE The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.
$77.4k-96.8k yearly Auto-Apply 9d ago
Social Work Case Manager II
Santaclara Family Health Plan 4.2
San Jose, CA job
FLSA Status: Exempt Department: Case Management Reports To: Health Services Management Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521 The Social Work Case Manager is responsible for providing on-going case management services for Santa Clara Family Health Plan (SCFHP) members. As a SCFHP member advocate, the Social Work Case Manager II facilitates communication and coordination among all participants of the care team, to ensure member identified goals and needed services are provided to promote quality cost-effective outcomes. Through the development and implementation of member individualized care plans, the Social Work Case Manager II provides psychosocial and behavioral case management support to help coordinate resources and services for individuals across the healthcare and social services continuum, and facilitates the use of available healthcare benefits in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. * Conduct, review and document comprehensive psychosocial assessments for assets and deficits and on-going follow-up interventions to measure progress towards meeting goals as they relate to a member's physical, psychosocial, environmental, safety, developmental, cultural and linguistic needs. * Maintain case files by ensuring that they are documented timely in accordance with SCFHP policies and procedures, state and federal requirements and organized in a manner that adheres to standards for audit requirements. * Facilitate involvement of the member and/or family/responsible party for development and implementation of a member specific care plan which includes individualized prioritized goals. Provide appropriate social work interventions to members and/or family/responsible party with related psychosocial process teaching and information. * Coordinate member's care with primary care providers, specialists, behavioral health providers, Long Term Services and Supports providers, public services, community providers, and vendors as necessary and appropriate to assist member to achieve and maintain optimal level of functional independence to reside in the most appropriate level of care. * Communicate and coordinate member's psychosocial and behavioral health needs with member's interdisciplinary care team including SCFHP internal staff, as well as the member's providers, specialists, public services, community agencies and vendors to ensure appropriate care plan development and successful coordination of benefits and services aligned with the member's preferences. * Assist member's interdisciplinary care team in understanding social and emotional factors related to health condition and potential barriers and coping mechanism to accessing care. * Provides guidance, education and referrals to help members seek solutions to specific social, cultural, or financial problems that impact their ability to manage their health care needs. * Conduct telephonic and in-person interview, baseline assessments, survey, assess self-care ability, assess knowledge and adherence, comprehensive clinical assessments as indicated, and developing member centric plan in the office, home, facilities, clinics, or community settings. * Collaborate with team members on cross-departmental improvement efforts, organizational and departmental objectives, quality improvement projects, optimization of utilization management, and improvement of member satisfaction. * Attend and actively participate in Health Services meetings, operational meetings, training and coaching sessions, including off-site meetings as needed. * Perform other duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. * Master's Degree in Social Work, or related field. (R) * Certified Case Manager (CCM). (D) * Active California registered Licensed Clinical Social Worker (LCSW) without restriction. (R) * Minimum three years of experience in social work, behavioral health, or case management, or education or certifications, or equivalent experience. (R) * Knowledge of social case management and conflict resolution. (R) * Knowledge of long-term services and supports, behavioral health and/or relevant public services and community resources. (R) * Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R) * Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills. (D) * Experience working with designated member population (e.g. behavioral health, seniors and persons with disabilities, children). (D) * Ability to work within an interdisciplinary team structure. (R) * Travel to off-site locations for work such as in office, home, facility, clinic, and other community settings. (R) * Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R) * Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the operations as dictated by business needs. (R) * Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case management programs. (R) * Ability to use a keyboard with moderate speed and a high level of accuracy. (R) * Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing as mandated by social work scope of practice. (R) * Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) * Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) * Ability to maintain confidentiality. (R) * Ability to comply with all SCFHP policies and procedures. (R) * Ability to perform the job safely and with respect to others, to property and to individual safety. (R) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: * Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels.
$51k-69k yearly est. 60d+ ago
Associate Specialist, Appeals & Grievances
Molina Healthcare 4.4
Long Beach, CA job
Provides entry level support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). Essential Job Duties • Enters denials and requests for appeals into information system and prepares documentation for further review. • Researches claims issues utilizing systems and other available resources. • Assures timeliness and appropriateness of appeals according to state, federal and Molina guidelines. • Requests and obtains medical records, notes, and/or detailed bills as appropriate to assist with research. • Determines appropriate language for letters and prepares responses to member appeals and grievances. • Elevates appropriate appeals to the next level for review. • Generates and mails denial letters. • Provides support for interdepartmental issues to help coordinate problem-solving in an efficient and timely manner. • Creates and/or maintains appeals and grievances related statistics and reporting. • Collaborates with provider and member services to resolve balance bill issues and other member/provider complaints. Required Qualifications • At least 1 year of experience in claims, and/or 1 year of customer/provider service experience in a health care setting, or equivalent combination of relevant education and experience. • Customer service experience. • Organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. • Effective verbal and written communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting experience. • Completion of a health care related vocational program (i.e., certified coder, billing, or medical assistant). 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.
$32k-62k yearly est. Auto-Apply 7d ago

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Updated January 21, 2026

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