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Title:currently there are no job openings at this department
Title:Claims Analyst (2)
Grade: 4
Shift: Monday – Friday 9:00am – 5:00pm
Location: 37th St
Date Posted: 5/14/09
Job Summary:
The Claims Analyst is responsible for the life cycle of claims. He/she will adjudicate claims using independent judgment, interpretation of Contracts, Medical Policy, Medical Management, Authorizations, and Historical Data
Job Skills:
Analyze and adjudicate pended claims generated from Rubi Reporting System
Research Health Plus member files when a discrepancy exists or eligibility is questioned.
Analyzes claims to determine appropriate reimbursement for par and non-par providers.
Analyzes claims by type of service interpreting Medical and Claim Policy and Procedures
Reviews provider refunds and applies adjustment workflows
Responsible for the adjudication of complex claims for various types of service
Refers claims with security restrictions and/or high dollar allowable to Senior Claims Analysts
Interacts with providers on the telephone or by correspondence, often dealing with Doctors, Medical Office Managers, Health Officials, Hospital Billing Management, and Billing Services
Determines NYS member eligibility using EMEV
Document and track claim inquiries using Customer Focus
Review correspondence to determine post payment accuracy
Maintains all documentation for claims processing reference manuals
Required Skills and experience:
• Strong data entry skills (10,000 keys strokes alpha/numerical)
• Must be able to work independently
• Must be able to exercise judgment
• Must be able to interact with providers in a professional manner and be capable of high professional levels of communication
• Must be able to work on computer systems, accessing multiple files
• Claims processing, medical billing or related work skills required
• Knowledge of medicine and medical terminology, CPT and ICD.9 and DSM codes.
• Must have good mathematical skills to maintain and monitor batch controls and
• Calculate payments and provide other statistical data
• Must be able to work under general guidance of Claims Supervisor and Sr. Claims Analyst with little direct supervision
• Must be meticulous and pay attention to detail
• 1yr - Prior Medical Claims processing or billing experience
• Customer Service experience
Required Education
High School Graduate, some college preferred
Title:currently there are no job openings at this department
Title:currently there are no job openings at this department
Title:currently there are no job openings at this department
Title:currently there are no job openings at this department
Health Education & Community Outreach
Title:currently there are no job openings at this department
Title:currently there are no job openings at this department
Title:Senior Health Services Representative Job Summary: Principal Duties and Responsibilities: *Essential Functions Job Specification: Required Education and Experience:
Grade:5
Location:Adams St.
Shift:Days Monday – Friday
Date Posted:6/29/09
The Senior HS Representative is responsible for training all new employees and assisting the Supervisor in projects or work assignments. The Representative will continue to perform the standard HS Representative job duties.
· Responsible for monitoring calls on the Call Center during peak hours and in the absence of the supervisor.
· Will team up with the department supervisor to evaluate the representatives to ensure that the providers and
members are receiving quality service, including auditing call center and data entry performance.
· Orients and trains new HS Representative on departmental functions.
· Retrains the HS Representative on departmental policies and procedures on a quarterly basis
· Understands the overall benefits for Health Plus (Medicaid), Child Health Plus and Family Health Plus.
· Works cooperatively with other staff in meeting overall goals of developing customer service strategies, plans and materials, a certain degree of latitude and creativity is required.
·Establishes and maintains a good relationship with internal and external customers.
·Performs a variety of projects assigned by the supervisor.
·Other duties as assigned by Health Services Supervisor.
Must be able to communicate effectively orally and in writing in order communicate the outcome of problem solving efforts.
Must have good customer relation skills and be able to communicate effectively with members, providers and other Health Plus staff.
Must have some knowledge of call center management
Must have good understanding of the work flow between Health Services and the other departments in Health Plus.
Must be highly organized and be able to perform multiple tasks simultaneously.
Must be able to work autonomously and require minimal direct supervision.
Must be able to troubleshoot on interdepartmental issues.
Must have good leadership skills.
·High School Diploma or GED required
·At least two years experience working in health care required; preferably managed care or HMO setting
·Must be willing and able to work flexible hours including evenings if required by the health plan
·Experience working directly with providers and patients is preferred
Title:Health Services Representative (2)
Grade: 3
Location: Adams St.
Shift: Days Monday – Friday
Date Posted: 6/29/09
Job Summary:
The HS Representative is responsible for servicing the Health Services call center, processing requests for medical services, assisting providers in locating in-plan providers, and working in partnership with the clinical staff to coordinate services for Health Plus members within the appropriate network of care.
Principal Duties and Responsibilities: *Essential Functions
• Responsible for servicing a physician call center, consisting of incoming and outing calls and faxes from physicians, hospitals and other health care providers requesting approval for health care services.
• Processes complex requests for medical services, including
1) verifying eligibility;
2) obtaining initial medical information and performing some basic analysis such as determining if the request for specialist matches the diagnosis given and
3) entering the demographic and medical information in the computer system.
4) Responsible for complete data entry in computer requiring knowledge of medical terminology and basic coding terminology.
• Based upon health plan policy and where applicable;
makes a determination based upon the medical information given and issues an approval by calling or faxing a response to the provider or;
refers the case to clinical staff (registered nurses or social workers) as appropriate for further review.
• As part of the authorization process, when a request is made for out-of-network services, redirect members and physicians to participating providers and facilitate the access to services to prevent delays in treatment.
• Enters new cases for Disease Management Program in the computer system and refers them to the registered nurse for review.
• Sends the Disease Management questionnaire and Health Education literature to the member.
• Administers the Asthma Health Risk Assessment over the phone and documents this in the computer if the member calls in; documents the result of the Disease Management Questionnaires returned in the mail in the DM section of the Facets computer system.
Required Education and Experience:
• High School Diploma or GED required
• At least two years experience working in health care required; preferably managed care or HMO setting
• Must be willing and able to work flexible hours including evenings if required by the health plan
• Experience working directly with providers and patients is preferred
Title:Database Analyst Principle Duties & Responsibilities:
Location: 37th St
Shift: Monday – Friday 9:00am – 5:00pm
Grade: 9
Date Posted: 6/26/09
Job Summary:
The Database Administrator (DBA) performs a variety of complex administrative and technical work in managing the database and data dictionaries of the enterprise, troubleshooting and system management. It is the DBA’s responsibility to ensure optimum performance of corporate databases.
• Supervises and modifies as needed the data dictionary(s) of the organization.
• Documents data dictionary(s) as needed as well as preserving standards and controls the necessary infrastructure process.
• Helps with database design, programming and troubleshooting and management of problems affecting IT and enterprise database applications, as well as developing the area for future expansion.
• Performs production and test installations and maintenance work both during normal business hours and outside normal business hours as required.
• Works closely with other ITS staff including Application Development, Application Support and Data Integration, Operations and Quality Assurance
• Administers the database environments including configuration, security, resource monitoring and reporting, tuning and troubleshooting, backups and restore.
• Coordinates software issues within the MIS department including applications and operations.
• Helps to keep the organization knowledgeable on leading edge database technology offering the highest reliability and performance possible.
• Provides backup support for related positions as needed.
• Perform related duties as assigned.
Required Skills
1. Excellent written and verbal communication skills.
2. Excellent working knowledge of database theory as well as hands on knowledge of industry standard databases (i.e. SQL Server, Sybase, Oracle, etc.)
3. Ability to work independently with little supervision.
4. Works well under pressure and possess good troubleshooting skills.
5. Must be extremely organized.
Required Education and Experience
1. BA/BS. MA/MS preferred.
2. Minimum 4 years previous hands on database experience.
3. 1 year prior managed care experience preferred.
Title:Field Marketing Supervisor Job Summary: Principle Duties and Responsibilities:
Grade: 7
Shift: Variable Schedule/Hours
Location: To Be Determined
Date Posted: 6/26/09
Under the direct supervision of the Regional Marketing Director, the Field Marketing Supervisor is responsible for maintaining the daily operations of the department, as well as demonstrating proven methods of coordinating to the Marketing Representatives staff and troubleshooting any discrepancies in the established departmental and company wide policies and procedures.
• Maintains and analyzes collected data from events.
• *Enforces departmental policies and procedures.
• Supports and trains department staff.
• *Outreaches to government and civic organizations.
• *Conducts monthly evaluations (in-house and on-site).
• *Schedules and monitors Marketing Representatives at events when necessary.
• Submits and records department timesheets.
• *Motivates and maintains a professional working relationship among the staff.
• Develops public relations activities and programs that support enrollment efforts.
• Coordinates and keeps abreast of enrollment process between the office of the Deputy Mayor, HRA, and the Educational Enrollment Units.
• *Works closely with the Special Events Coordinator to identify and develop marketing opportunities.
• Establishes and meets annual enrollment projections.
Required Skills, Experience and Education:
• Minimum three to five years of supervisory experience. Experience in the Health industry preferred.
• Valid Driver’s license.
• Able to work a flexible work schedule including weekend work as required.
• Ability to maintain and organize structure within the department.
• Ability to communicate effectively in both verbal and written form.
• Ability to troubleshoot any situation in-house and on-site.
• Knowledge of MSWord, MSAccess, MSExcel, MSPowerpoint, MSOutlook,
• Associates degree in Communication, Marketing or related education.
Title:Marketing Representative (2) Staten Island (1) Shift: Variable days and variable hours. You will need to be available to work some weekend and holidays.
Grade: 3
Location: Bronx (1)
Languages: Bilingual English/Spanish or Second Language to be determined by Dept
Bilingual-English and Second Language to be determined by Dept
Date Posted: 6/26/09
Job Summary:
The Marketing Representative is responsible for identifying, educating, and enrolling qualified individuals and families into the three managed care plans operated by Health Plus: Child Health Plus, Health Family Health Plus, and Care Plus. During the first six months of employment, the
Marketing Representative will be in a training program. The Marketing Manager and Supervisor will provide regular feedback and evaluation on his/her performance.
Principal Duties and Responsibilities: *Essential Functions
*Markets Child Health Plus, Health Care Plus and Family Health Plus programs to prospective Members, which may be done on a one-on-one or group basis.
*Understands the overall requirements for Medicaid eligibility, Health Care Plus eligibility and Child Health Plus eligibility.
*Responsible for assuring those applications are accurately completed and that individuals are actually eligible to be enrolled in the respective programs.
*Helps the Marketing Manager and Supervisor identify potential new markets in the community.
Works cooperatively with other Marketing staff. Meets overall team efforts.
*Makes marketing presentations to community organizations, local businesses, pharmacies and providers to inform their staff and clientele about programs and enrollment process.
Identifies special events that will assist the Marketing Department in promoting managed care in general and/or the Child Health Plus, Health Care Plus and Family Health Plus programs.
*Representatives must conduct enrollment activities.
*Works closely with Member Services and the Call Center to close all leads.
Responsible for maintaining appropriate records, including activity reports, expense reports.
Other duties as assigned by the Director of Marketing and Business Development, Assistant Director of Marketing and Business Development, the Marketing Manager or Supervisor.
Required Skills:
• Excellent organizations skills.
• Good oral communication skills.
• Must be self-motivated.
• Must be willing and able to work in a multi-cultural and multi-ethnic work environment.
• Must present an appropriate appearance and demeanor consistent with representing Health Plus in the community.
Required Education and Experience:
• High School diploma or G.E.D required.
• Health care and some marketing, sales and/or customer services experience preferred.
• Second language skills, if needed, to be determined by department
• Clean, valid NYS driver license a car is a plus.
Title:Regional Marketing Manager –Staten Island Job Summary: Required Education:
Grade: 10
Shift: Variable Schedule-Days/Hours
Location: Brooklyn
Date Posted: 6/12/09
The Regional Marketing Manager is responsible for recruiting, training, assigning, directing, motivating, and evaluating Marketing Representatives and Marketing Managers or Supervisors in at least two Districts or an entire borough.
The Regional Marketing Manager coordinates the work of the Marketing Representatives with other marketing functions.
Principal Duties and Responsibility:
• *Recruits, hire, and trains Marketing Supervisors and Marketing Representatives for their region.
• *Supervises and directs Marketing Managers and Representatives to ensure their success in targeting and soliciting prospective members for the region.
• * Through the Marketing Supervisors, assigns representatives to designated Income Services Centers, Primary Care Locations, and Community Based Organizations.
• *Together with the Marketing Supervisors, develops public relations activities and programs that support enrollment efforts for the assigned region.
• Assures that the Marketing Supervisors coordinate and keep abreast of the enrollment process between the office of the Deputy Mayor, HRA, and the Educational Enrollment Units.
• *Works closely with the Special Events Managers and Field Supervisors to identify and develop marketing opportunities for the region.
• *Establishes and assists the Marketing Supervisors in meeting annual enrollment projections for the region.
• *Works closely with Member Services to identify and resolve issues associated with marketing practices.
• Performs other duties as assigned from time to time by the Regional Director, Marketing and Director of Marketing.
Required Skills and Experience:
• Capable of training and motivating a multiethnic marketing staff.
• Good oral and written presentation skills.
• Seven years experience in sales and marketing, preferably in the field of Managed care or other health services.
• Five years supervisory experience.
• Valid Driver’s license and full time use of vehicle.
• Bachelors degree; appropriate experience may substitute for education requirement.
Title:Medicare Marketing Representative (5 Openings) Principal Duties and Responsibilities: *Essential Functions
Shift: Variable Days/Schedule
Location: Borough Assignment-TBD
Date Posted: March 26, 2009
Job Summary:
The Medicare Marketing Representative is responsible for identifying, educating, and enrolling qualified individuals into the Medicare managed care plan operated by Health Plus. During the first six months in the position, the Medicare Marketing Representative will be in a training and performance evaluation period. The Medicare Sales Manager will provide regular feedback and evaluation on his/her performance.
• Internal Applicants will be sponsored for Certification/Health Insurance Licensing.
New York State Health Insurance License is required.
• *Markets Health Plus Elite Medicare to prospective Members, which may be done on a one-on-one or group basis.
• *Understands the overall requirements for Medicare eligibility.
• *Responsible for assuring those applications are accurately completed and that individuals are actually eligible to be enrolled in the program.
• *Helps the Medicare Sales Manager identify potential new markets in the community.
• *Works cooperatively with other Medicare Marketing staff. Meets overall team efforts.
• *Makes marketing presentations to community organizations, local businesses, pharmacies and providers to inform their staff and clientele about programs and enrollment process.
• *Representatives must conduct enrollment activities.
• *Works closely with Member Services and the Call Center to close all leads.
• Responsible for maintaining appropriate records, including activity reports, expense reports.
• Other duties as assigned by the Medicare Marketing Sales Management.
Job Specification:
• Excellent organization skills.
• Good oral communication skills.
• Must be self-motivated.
• Must be willing and able to work in a multi-cultural and multi-ethnic work environment.
• Must present an appropriate appearance and demeanor consistent with representing Health Plus in the community.
• Able to work flexible hours (shifts, weekends etc.) as needed
Required Education and Experience:
• Successful track record in Field Marketing is required.
• Valid NYS Driver’s License and car are preferred.
• Bi-lingual skills required. Second language to be determined by the department.
• NY State Health Insurance License is required.
Marketing Business Development
Title:currently there are no job openings at this department
Title:currently there are no job openings at this department
Title:Retention Representative (3)
Grade: 3
Location: 37th St.
Language: Bilingual - English and Spanish
Shift: Variable days and Variable Hours
Date: 6/5
Job Summary:
The Recertification/Retention Representative is responsible for the overall follow up and renewal of our members into CHPA &B/FHP as well as the retention of all members who are signed up presumptively into the various plans. This is done through identifying, educating, and re-enrolling qualified individuals and families into the Health Plus programs they qualify for. In addition, enrolls new members when possible. During the first three months of employment, the Recertification/Retention Representative will be in a training program. The Marketing Manager and Supervisor will provide regular feedback and evaluation on his/her performance.
Principal Duties and Responsibilities:
Call up all existing members who are either up for renewal and/or who are due to terminate enrollment because of presumptive eligibility
Markets Child Health Plus A/B, Health Care Plus and Family Health Plus programs to prospective Members, which may be done on a one-on-one or group basis.
Follows up with members by mail and conducts house calls if necessary
Understands the overall requirements for Medicaid eligibility, Health Care Plus eligibility and Child Health Plus A/B eligibility.
Responsible for assuring that applications are accurately completed and that individuals are actually eligible to be enrolled in the respective programs.
Works cooperatively with other Marketing staff. Meet overall team efforts.
Recertification/Retention must conduct enrollment activities.
Works closely with Member Services and the Call Center.
Responsible for maintaining appropriate records, including activity reports.
Other duties as assigned by the Director of Marketing and Business Development, Assistant Director of Marketing and Business Development, the Marketing Manager or Supervisor.
Job Specification:
Excellent organizational skills.
Good oral communication skills.
Must be self-motivated.
Must be willing to work flexible hours, flexible weekends, holidays and overtime as needed.
Valid Driver’s license
Vehicle a plus
Must be willing and able to work in a multi-cultural and multi-ethnic work environment.
Must present an appropriate appearance and demeanor consistent with representing Health Plus in the community.
Required Education and Experience:
• High School diploma or GED required.
Title:currently there are no job openings at this department
Title:Provider Services Representative Job Summary: Principal Duties and Responsibilities: *Essential Functions Required Skills: Required Education and Experience:
Grade: 5
Location: Adams St
Shift: Monday – Friday 9:00AM – 5:00PM
Date Posted: 6/29/09
Under the overall direction of the Director for Network Management and Provider Relations and under the direct supervision of the Provider Relations Manager, the Provider Services Representative is responsible for insuring timely resolution of all provider inquiries.
· First line response to all telephone, fax, or mail inquiries for providers and provider office staff
· Tracks all inquiries in Customer Focus
· Provides real time response to inquiries related to credentialing status, status of authorizations, status of submitted claims and member Eligibility
· Responds to requests for HEALTH PLUS provider materials (including Directories, Provider Manuals, Educational Materials, Forms)
· Provides initial intake and response to provider issues and complaints. In conjunction with Provider Relations Associates, investigates and resolves provider issues and complaints. The PSR is responsible for tracking and insuring timely resolution
· Responsible for identifying and tracking provider issues and referring frequent issues to Provider Relations Manager in order to address potential system changes
· Responsible for telephone surveys of Provider Offices
· Responsible for both oral and written correspondence with Providers
· Other activities and duties as assigned by the Provider Relations Manager
Must be able to work with people at all levels within and outside the organization and facilitate work group processes
Must have excellent interpersonal skills and be able to work with providers and provider staff
Must know Microsoft Word for Windows and must have good spreadsheet application skills. Experience with database management programs is a plus
Must be willing to take classes in applicable Health Plus applications
B.A. or B.S. degree or equivalent experience preferred.
Experience in Provider Relations in a managed care organization preferred.
Title:currently there are no job openings at this department
Title:Member Services Representative (4)
Grade: 3
Location: 37th Street
Shift: To be Determined
Language: (1) English & Spanish, (1) English & Arabic (2) English & Mandarin & Cantonese
Date Posted: 6/26/09
Job Summary:
The Member Service Representative is responsible for orienting HEALTH PLUS members on how to use the plan and provider network appropriately, addressing concerns, grievances and disenrollments expeditiously, assisting in the overall development and implementation of programs to increase member satisfaction.
Principal Duties and Responsibilities: *Essential Functions
• Serves as an advocate for HEALTH PLUS members within a managed care environment to ensure their satisfaction with the plan.
• Orients new members to HEALTH PLUS through telephone orientation sessions.
• In coordination with the Patient Care Coordinators and Outreach staff, follows up with members who need additional education/orientation about how to use HEALTH PLUS services.
• Maintains and tracks all member contact in Customer Focus and follows up on cases on a timely basis with appropriate departments.
• Understands the overall requirements for Medicaid eligibility, HEALTH CARE PLUS eligibility, and Child Health Plus eligibility.
• Maintains ongoing communication with provider network, participating pharmacies and government managed care representatives
• Responds to inquiries and member issues concerning Plan benefits on a timely basis
• Makes the necessary decision and effort to retain enrollees so as to achieve and maintain enrollment at projected levels.
• Meeting Call Center standards by answering calls within 20 sec keeping calls to a minimum of 2:00 minutes per calls and maintaining an average of 50-60 calls a day (including walk-ins).
• Using proper telephone etiquettes when speaking to customers
• Maintaining attendance
• Punctuality
• Performs other related duties as assigned or requested
Required Skills:
• Must have good organizational skills.
• Must be able to communicate effectively both orally and in writing in order to solve problems.
• Must be self-motivated
• Must type 25-30 wpm
Required Education and Experience:
• High School Diploma or GED required.
• At least one (1) year of customer service experience required.
• Must be bilingual
Title:Office Manager
Grade: 8
Location: Adams St
Shift: Variable Days 9:00am – 5:00pm
Date Posted: 6/26/09
Job Summary:
The Office Manager has overall responsibility for Health Plus’ internal administrative systems, facilities and plant management. This administrative position coordinates activities with Chiefs, Directors, Managers, etc. to assure that Health Plus internal operations run smoothly; plans for facility changes and improvements, and assures that the facility is properly maintained. This position supervises the Health Plus Receptionists, Office Supervisor, clerk and on/off site maintenance Personnel.
Principal Duties and Responsibilities: *Essential Functions
• Space planning, including layout of offices, work and storage spaces and moves.
• Furniture and equipment planning.
• Purchasing functions, including vendor selection, record keeping, ordering of all equipment, supplies and stationary for assigned locations.
• Maintenance of furniture, equipment and office supply inventories.
• Design, implementation and maintenance of office automation, including selection and evaluation of equipment.
• Establishment and maintenance of personnel systems, time keeping, time cards, for assigned staff.
• Establishment and maintenance of security systems for all sites.
• Assists in the preparation of operations budget vs. actual financial data.
• Interaction with all satellites and locations, regarding equipment, personnel, etc.
• Prepares required check requests, purchase orders, service contracts as required.
• Maintenance and supervision of all mailroom functions at 205 and 195 Montague.
• Supervises receptionists, maintenance workers and security services and oversees the secretaries.
• Assists in the hiring of staff for receptionists, office supervisors, and mailroom clerks.
• Oversees that the HIPPA compliance is enforced in all my assigned sites.
• Orders business cards for the entire Health Plus staff along with stamps for the marketing department and stationary note pads.
• Conducts periodic facility inspection of all the assigned sites to ensure that maintenance and repairs were done in an appropriate time by the Office Supervisor.
• Position does require 24/7 availability for emergency situations.
Job Specification:
• Good organizational skills and ability to multi-task.
• Ability to work well with people in different departments and cultures and various locations.
• Personal computer skills, including word processing programs, Microsoft Word for Windows, spreadsheet applications such as Excel for Windows.
Required Education and Experience:
• Associate’s degree in office and/or business management. Bachelor’s degree is a plus. Appropriate experience can substitute for education.
• Five years of work experience, with progressive responsibility for office and facilities management or administration.
Title:Data Analyst
Grade: 6
Shift: Monday – Friday 9:00am – 5:00pm
Location: Adams St
Date Posted: 6/26/09
Job Summary:
Under the overall direction of the Manager of Credentialing, the Data Analyst is responsible for providing and coordinating technical and operations support to Provider Relations Department.
Principal Duties and Responsibilities: *Essential Functions
• Assists management in designing reports in monitoring network adequacy; ensures the timeliness and completeness of the reporting generations and distribution. They include:
o Network Assessment Map Report
o Provider Capacity Report
o Network Growth Report
• In conjunction with IT, and other Provider Relations areas, responsible for the integrity of the Health Plus Provider database and other provider listings (e.g. provider contact listings)
o On a monthly basis, develops and generates reports for areas to review the HEALTH PLUS Provider database for accuracy and completeness
• In conjunction with MIS and Credentialing, responsible for the Health Provider Network quarterly submission
• Responsible for the production of all HEALTH PLUS PROVIDER DIRECTORIES(printed version and online version, full version and language version)
• Monitors and supports the GeoAccess Enterprise Directory System
• Acts as a liaison between IT and PR to develop the enterprise reporting application
• Responsible for report generations to support all reporting needs in all PR areas
• Other activities and duties as assigned by the senior Data Analyst, the Senior Manager of Provider Relations Operations, and the Director of Network Development and Provider Relations.
Required Education and Experience:
• Bachelor degree or an associates degree with at least one year experience in Provider Relations with a managed care organization.
Title:Provider Relations Associate
Grade: 6
Location: TBD
Shift: Monday – Friday 9:00AM – 5:00PM
Date Posted: 6/26/09
Job Summary:
Under the overall direction of the Director for Network Management and Provider Relations and under the direct supervision of the Provider Relations Manager for his/her region, the Provider Relations Associate assists in the recruitment and orientation of HEALTH PLUS providers. The Provider Relations Associate is also responsible for maintaining ongoing contact with providers and their office staff.
Principal Duties and Responsibilities: *Essential Functions
• Assists in identifying, recruiting and negotiating contracts with network providers
• Implements programs to orient providers and provider office staff to HEALTH PLUS
• Assists in the development and implementation of educational programs for provider and provider staff
• Monitors provider corrective action plans
• Distributes provider manuals and orients provider staff to manuals
• Responds to provider inquiries and complaints
• Implements provider surveys
• Assists with the credentialing process
Job Specification:
• Must be able to work with people at all levels within the organization and facilitate work group processes
• Must have excellent interpersonal skills and be able to work with providers and provider staff
• Must know WordPerfect or Microsoft Word for Windows and must have good spreadsheet application skills. Experience with database management programs is a plus
• Must be willing to take classes in applicable HEALTH PLUS applications
• This position will require frequent travel within the New York metropolitan area and will require use of a personal vehicle
Required Education and Experience:
• B.A. or B.S. degree
• Three years experience in health care delivery or insurance with at least one year experience in a managed care organization
Title:Manager of Hospital Reimbursement
Grade: 9
Shift: Days
Location: Adams Street
Date Posted: 4/24/09
Job Summary:
Reporting to the Director of Network and Provider Field Services, this staff member is responsible for insuring that financial terms of agreements are interpreted accurately and implemented throughout Health Plus.
Principal Duties and Responsibilities:
• As part of the Contract Implementation Process, reviews all new and amended hospital and IPA Agreements to insure that all covered services are addressed in the financial terms of the agreement
• Insures that the financial terms of all new and amended hospital and IPA Agreements are forwarded to Model Office for configuration
• Insures that all provider relationships covered under the hospital and IPA agreements are addressed by Contracting, Contract Implementation and Provider Operations
• Works with Director of Provider Operations to insure that Provider Setup conforms to the Contracted Agreement
• Provides analytic support to the Hospital Teams
• Researches financial impact of and makes suggestions for alternative reimbursement arrangements
• Trains Medical Management staff in:
o Hospital Reimbursement which includes
DRG pricing for Medicaid and Medicare
APC pricing for Medicare
APG pricing for Medicaid
RBRVS and Medicaid reimbursement
• In conjunction with VP of Finance and Chief Medical Officer develops and implements strategies to increase risk based premiums
• Analyzes disputed claims and makes recommendations on:
o Correct Payment of disputed claims
o Changes to negotiated Agreements or Medical Policy to address unexpected findings in payment policy
• Reviews findings of post-payment audits and makes recommendations for improvement
• Serves on iHealth Steering Committee
• Serves as Medical Management Expert in Networx Pricer™
• Serves on Medical/Claims Policy Committee
• Other duties and responsibilities assigned by VP of Network Development and Director of Provider Relations
Required Education:
• Masters Degree in Business, Finance, Accounting or Health Services Management
• 5 years experience in financial analysis in a hospital or managed care organization
• Expertise in Microsoft Excel™; knowledge of Access™ or Microsoft SQL™ highly desirable
• Ability to apply APC, APG and DRG reimbursement for Medicare and Medicaid financial models
• Experience in managing risk based premiums preferred
Title:Field Supervisor
Grade: 8
Location: TBD
Shift: Monday – Friday
Date Posted: 6/26/09
Job Summary:
The Provider Relations Field Supervisor is responsible for overseeing the field activities of the Provider Relations Associates
Principal Duties and Responsibilities: *Essential Functions
• Provides Field Supervision to Provider Relations Associates
• Assists Provider Relations Associates in provider recruitment
• Responsible for field training of Provider Relations Associates
• Responsible for monitoring the field activities of Provider Relations Associates
• Responsible for addressing any issues that develop between Provider Relations and the Providers’ staff
• Responsible for insuring that all directly contracted PCPs in their service area have quarterly visits by Provider Relations Associates
• Responsible for insuring that all facilities have monthly visits
• In conjunction with Provider Relations Managers, identifies areas in need of primary care and specialist referrals
• Insures that Provider Relations Associates submit provider updates on a timely basis
• Reviews all provider complaints for providers in service area and ensures timely responses
• Assist Provider Relations Associates in claims research
• Conduct provider orientations for large groups/facilities
• Other activities and duties as assigned by the Director of Network Management and Provider Relations and the Provider Relations Manager
• Project Manager for Corporate Initiatives and Provider Relations
Job Specification:
• Must be able to work with people at all levels within the organization and facilitate work group processes.
• Must have excellent interpersonal skills and be able to work with providers and provider staff.
• Must have excellent written and oral communication skills, including experience in large group presentations.
• Must have excellent computer skills. Must know Microsoft Word and Excel for Windows.
Required Education and Experience:
• B.A or B.S. degree
• Two years experience in Provider Relations or related field within a managed care organization
Title:currently there are no job openings at this department
Title:currently there are no job openings at this department
Title:currently there are no job openings at this department
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