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Member Services Team Manager
Position Description:
The Member Services Team Manager is responsible for the development, implementation, enhancement and support of call center systems, technologies and strategies. Oversees the daily operations of all Member Services Department functions; ensures activities run smoothly and efficiently; promotes the image of the company in a professional and positive manner; provides supervision, guidance, coaching, recognition, motivation and training to department personnel; participates in marketing campaigns and product launches; attains sales, quality control and customer service goals. Performs direct supervisory duties of department staff and coordinates staff for coverage in all related areas.
Educational Requirements:
- Associate Degree with a minimum of 5 years customer service experience; or a high school diploma (or equivalent) with minimum 6 years customer service experience, required
- Bachelors degree, preferred
- 1-3 years experience in health care/managed care, preferred
- Prior call center leadership position, preferred
Member Services Representative Level I
Position Description:
The Member Service Representative (MSR) Level I receives and processes calls from customers, serves as the end to end point of contact to resolve customer issues with impeccable customer service. Responsible for servicing assigned customers while making informed decision under the supervision of a Team Lead and/or Management. Analyzes and resolves issues to ensure customer satisfaction with all aspects of services rendered. Must demonstrate expertise in the execution of state and federal regulations as well as Universal Health Care Group policy, procedures and products.
Educational Requirements:
- High School diploma, or equivalent
- Two years customer service experience required
- Healthcare experience, preferred
Director, Special Needs Plan
Position Description:
The Director of Special Needs Plans is responsible for management of the requirements of the most vulnerable population of Medicare beneficiaries such as, the institutionalized, dual eligibles and those with chronic conditions.
This position will develop Universal Health Care's strategy to evaluate and maintain the standard of care for these beneficiaries in order to improve care and control costs, to meet or exceed the standards set by governmental agencies.
This position will be responsible for all compliance and reporting responsibilities for the special needs plans. This position also manages and develops department staff, it is expected to partner with internal constituents; particularly Case and Disease Management, Concurrent Review and Quality Management.
Educational Requirements:
- Unrestricted RN license in the State of Florida, required
- 5 years of health care management experience, including Medicaid, ABD or work with chronically and medically fragile members.
- Experience in complying with NCQA and CMS regulations.
Case Manager, Utilization Management
Position Description:
To participate in the case management process, acting as a patient advocate, seeking and coordinating solutions to the health care needs of members. The case manager develops a case management plan with long and short-term goals and coordinates inter-disciplinary services providing members with quality services to meet established goals.
Responsibilities:
- Develops a case management plan based on an assessment of the member’s clinical and psychosocial status.
- Acts as a liaison between members and providers.
- Assists members in obtaining routine and/or complex medical care.
- Ensures that each member’s privacy is protected during the process of coordinating care services, consistent with confidentiality requirements in 45 CFR parts 160 and 164, specifically regarding the privacy of individually identifiable health information.
- Documents enrollment of the member in the case management program in the case management module of the Fortuna System. Documents all subsequent interactions with the member in the Fortuna System.
- Contacts the member at regular intervals based on the assigned case management level to determine current status, identify any issues or member concerns, educate the member about their condition and assist in the coordination of care/services.
- Maintains case files and provides assistance with appropriate documentation.
- Participates in scheduled case management rounds with the UHC Medical Director.
- May include the management of complex case management cases and/or prenatal cases.
- Prenatal case management may also include the newborn enrollment process in conjunction with the Enrollment Department.
- Works in collaboration with the Disease Management Case Managers to identify members who would benefit from the Disease Management program.
- Follows accepted standards of practices through the use of evidence based medical principals, standards and practices.
- Promotes effective and efficient utilization of clinical resources.
Educational Requirements:
- Possession of an unrestricted RN/LPN/LVN license in the State of Florida is required.
- An equivalent combination of education and experience from which comparable knowledge and abilities can be obtained is necessary.
- One to two years of experience in managed care is required.
Utilization Management Technician
Position Description:
A Utilization Management Technician (UM Tech) provides support to UM Case Managers through data entry, filing and calling members. A UM Tech is expected to perform all duties with integrity and within the parameters of all compliance rules and regulations. Is a vital part of the success of the Utilization Management department through the high level of support that is required from the position.
Responsibilities:
- Data entry of pre-service requests and new in-patient hospital notifications
- Data entry of clinical information
- Perform and document hospital discharge calls
- Assist Case Managers with Member calls
- Prepares and mails member educational materials
- Check inbound call log in Fortuna for messages for Utilization Management department
Educational Requirements:
- High School Diploma, or equivalent, required
- Associates Degree, preferred
- Experience in a hospital setting or doctors office, preferred
Senior Medical Claims Analyst
Position Description:
The primary job of the Sr Medical Claims Analyst is to review and resolve the more complex professional and institutional claim issues to ensure that proper guidelines have been followed and that the claim was processed accurately. Responsible for analyzing, adjudicating and adjusting a variety of medical claims for payment. Assist with reviewing and analyzing high dollar adjustment claims. Also responsible for examining and evaluating claim submission patterns of health care providers to determine whether the patterns indicate the potential of health insurance fraud, abuse or waste.
This position requires a highest degree of compliance to HIPAA rules, as well as regulations from federal, state and local regulatory agencies.
Educational Requirements:
- Two years of college and two years of medical claims processing and research experience preferred.
- Also must have medical claims investigative experience
- Must have knowledge of professional and institutional claims processing and root cause analysis
- Project management, Coding and nursing experience are plusses.
- Excellent written and verbal communication skills
Senior Tax Analyst
Position Description:
Responsible for various tax compliance functions such as filing tax returns, responding to tax jurisdiction inquiries and reviewing operating system’s tax functionality in order to ensure tax compliance with government laws/regulations. Also, responsible for performing accounting tasks of a difficult nature requiring an experienced professional with knowledge of accounting principles and practices.
Responsibilities:
- Prepares assigned monthly balance sheet and income statement reconciliations including tax and commission related accounts.
- Identifies book/tax differences.
- Prepares quarterly federal and state income tax estimates.
- Prepares moderately complex journal entries.
- Reviews daily cash flow report entries.
- Interprets accounting data, analyzes reports and recommends action to be taken.
- Researches state and local jurisdiction inquiries as necessary. Provides documentation to the jurisdiction in order to resolve any outstanding issue.
- Assists Treasurer with federal and state tax audits by gathering and reviewing information requested by the auditor such as tax returns, supporting files, depreciation schedules, fixed asset invoices, etc.
- Identifies areas of opportunity for tax savings and/or refunds. Makes continuous efforts to identify process improvements in all areas of tax and treasury functions.
- Assists in the development and installation of procedures and controls.
Educational Requirements:
- Bachelor’s degree in Finance or Accounting
- 3 – 5 years of related experience
- Certified Public Accountant
- Public Accounting experience, preferably large national firm
Provider Operations Representative
Position Description:
This position is responsible for both the negotiation of physician/provider contracts as well as ongoing education/service to the physician/provider network in assigned market areas.
Responsibilities:
- Conduct a quarterly audit to identify network gaps, determine ongoing network needs, and provide written provider goals.
- Identify, on a semi-annual basis, opportunities for re-negotiation of contracts by line of business and provider category.
- Negociate rates that will achieve goals for Medical Loss Ratios (MLR).
- Act as liaison with physician/providers to facilitate open communication, excellence in service and provide assistance where needed.
- Notify Supervisor of trends and problematic areas within networks applying problem solving skills and offering solutions to issues.
- Maintain network stability as it relates to physician/provider terminations and panel by closing primary care physicians.
- Implement, through service visits, electronically, and telephonically, educational tools for physician/providers and their proctive staff.
- Maintain reporting requirements for provider data
- Partner and working effectively with Claims Department, UM, Member Services, and other internal/external staff.
- Maintenance of assigned Provider contract files.
- Work closely, in assigned markets, with the Marketing and Sales team and primary care physician practices to achieve/exceed membership growth projections.
- Conduct quarterly outreach calls to primary care physician offices and high-volume specialists.
- Conduct yearly visits to primary care physicians, specialists and ancillary providers.
- Manage provider demographic information changes and resolve identified problems.
- In conjunction with the department manager, develop and implement strategies for reduction of Medical Loss Ratios (MLR) in identified primary care physician practices.
- Abide by all compliance requirements to the Department of Insurance (DOI), Agency for Health Care Administration (AHCA) and the Centers for Medicare and Medicaid Services (CMS) as these apply to Provider Relations Department activities.
Skill Requirements and Preferences:
- Exceptional customer service skills, ability to conduct presentations, and strong public speaking skills.
- Highly self motivated, able to establish spport and interact well with physicians and individuals on all levels.
- Ability to positively motivate and influence others.
- Ability and willingness to travel.
- Proficient in all Microsoft Applications
Educational Requirements:
- Bachelor's Degree or equivalent combination of education and related experience, required.
- 3-5 years experience in managed care setting, health plan or large medical group administration, preferred.
- Valid Driver's License, reliable automobile and current insurance.
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