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Title:Behavioral Health Care Coordinator Specific Duties and Responsibilities: A. Inpatient Admission, Authorization, and Concurrent Review · Identifies, on a daily basis, all members who are currently hospitalized B. Outpatient Admission, Authorization, and Concurrent Review · Reviews and evaluates all requests for outpatient services according to medical necessity criteria, utilization management guidelines, and practice guidelines established by Health Plus C. Utilization Management/Quality Assurance · Tracks Emergency Department Utilization and intervenes whenever inappropriate use/over-utilization is identified D. Case and Disease Management · Identifies and refers members for case and disease management according to criteria and protocols established by Health Plus Specific Skills Educational/Work Experience Requirements
Grade: 8
Shift: Monday to Friday 9-5pm
Location: Adams Street
Date Posted: 3/14/08
Job Summary:
The purpose of this position is to ensure that Health Plus members obtain timely, cost-effective, quality behavioral health care in the appropriate setting. Responsibilities include, but are not limited to inpatient and outpatient admission review and pre-certification, coordination of continuing stay and discharge planning, coordination of behavioral health with other medical services, identification and referral of members for case management and disease management programs, and provision of case management and disease management services as assigned. In all areas the Behavioral Health Care Coordinator is charged with managing the delivery of care in an effective, professional and compassionate manner.
Under the direction of the Director of Behavioral Health and in coordination with the Health Plus Medical Director and the Behavioral Health Medical Director, the Behavioral Health Care Coordinator is responsible for the following:
· Prioritizes hospitalized patients according to the relevant policies and procedures
· Conducts initial inpatient review and authorization within established times frames for emergent and non-emergent admissions and determines the appropriateness of admission, anticipated length of stay, treatment plan, and potential discharge needs
· Documents the inpatient review in the computer system including: diagnoses, procedures, attending physician, treatment plan, anticipated length of stay and needs utilizing American Psychiatric Association, American Academy of Child and Adolescent Psychiatry, and other criteria, utilization management guidelines, and practice guidelines as established by Health Plus
· Performs concurrent review within established time frames and enters information in the computer system in a timely manner
· Promptly refers all cases not meeting approved medical necessity criteria, or cases where there is a question on quality of care, to the Behavioral Health Medical Director for review
· Participates in discharge planning process to ensure timely discharge, appropriate follow up and continuity of care
· Maintains a timely record of all activity in the computer system
· Prior authorizes those services that meet approved medical necessity criteria. Enters authorizations in the computer system
· Promptly refers any case that does not meet approved medical necessity criteria for prior authorization or cases where there is a question on quality of care to the Behavioral Health Medical Director for review
· Facilitates appointments for members who have difficulty obtaining an appointment, assists the PCP with behavioral health referrals. Assists the member in accessing services, providing patient teaching and support to facilitate compliance with the treatment plan.
· Facilitates appointments for members who have difficulty obtaining an appointment, assists the PCP with behavioral health referrals. Assists the member in accessing services, providing patient teaching and support to facilitate compliance with the treatment plan.
· Maintains a timely record of all activity in the computer system
· Tracks utilization of the 24 hour behavioral health call center service by reviewing the daily call reports and ensures that response is timely and follow up needs are met
· Reviews New Enrollee Health History Forms, prioritizes needs and conducts follow up phone interviews where necessary to ensure access to and continuity of care
· Identifies potential Quality Assurance/Risk Management issues and promptly refers cases to the Director of Behavioral Health/ Behavioral Health Medical Director/Health Plus Medical Director according to the established policies and procedures
· Prepares Case Summaries and actively participates in Case Conferences
· Oversees activities of the BHS Representatives and provides performance feedback to the Director of Behavioral Health
· Accepts and performs additional duties as assigned within the scope of knowledge and skills and in support of the goal of timely and efficient delivery of care
· Prioritizes levels of case & disease management required based on established protocols
· Manages behavioral health care and coordinates with other health services across the system of care through establishing and maintaining contact with the member, family/guardian as appropriate, behavioral health provider (s), primary care physician, and other involved professionals/agencies as necessary, according to established priority level and procedures for all assigned Case Management cases.
· Conducts disease management activities as assigned by the Director of Behavioral Health, including but not limited to reviewing available data and reports to identify suitable candidates, developing educational materials, and conducting member health education on selected topics.
· Demonstrate the ability to communicate effectively in English. Prefer ability to communicate effectively in a second language.
· Demonstrates self-motivation and possesses the ability to solve problems independently
· Demonstrates commitment to patient advocacy
· Demonstrates the ability to work with other professionals and para-professional staff in a collaborative manner. Must be a team player
· Possesses strong organizational skills and is able to handle multiple tasks simultaneously
· Displays a commitment to quality both in practice and documentation and is able to follow through on all projects in a timely manner
· Current New York State certified Social Worker or Psychologist
Title:Senior Claims Analyst Job Summary: Specific Duties and Responsibilities: Required Knowledge and Skills: Required Education & Experience:
Grade: 5
Location: 37th St
Shift: Monday – Friday 9:00AM – 5:00PM
Date Posted: 3/28/08
The Sr. Claims Analyst is responsible for the complex areas of the claims adjudication process. He / she will perform these duties using all documentation available to the claims department as well as communications with Health Services, the Medical Director’s office and other areas of Health Plus management. He/she assists the supervisor advising claims processors and claims analyst in claim adjudication issues as well as post adjudication payment authorization.
• Reviews inquiries from various Health Plus Management disciplines, readjudicates claims where necessary.
• Assists supervisor in training new candidates for Sr. Claims Analyst
• Answers questions presented by claim staff regarding any claims issues
• Interprets medical policy when necessary
• Questions health services on unique claim situations requiring clarification of authorization
• Interfaces with the Medical Director in review of unique claim circumstances
• Handles referred telephone inquiries including irate calls, and those referred by claims analysts
• Performs special studies and handles special projects at the request of the Supervisor, Manager or Director of Claims Administration
• In the absences of the supervisor monitors and controls unit workflow
• Handles complicated / complex claims based on analysis of medical and claim policy, medical authorizations, detailed medical notes in the Health Services system, as well as discussions with relevant Health Plus Management
• Identifies and reviews potential system problems and deficiencies and brings it to the attention of the supervisor and the Quality Specialists Identifies need for system modifications
o -Interfaces with:
o Provider Relations
o Member Services
o ITS
o Model Office
o Finance
o Outreach
o Health Services
• Analyzes system suspense reports on electronic media claims, adjudicating claims or developing for additional information
• Interprets complex provider contracts as identified by Director of Claims Administration and processes claims associated with these contracts
• Maintains claims inventory and accuracy statistics for the area and reports same to supervisor
• Ability to work independently
• Must work well with people
• Must be able to interact with providers in a professional manner.
• Excellent verbal, written, and presentational skills
• Must have knowledge of medical terminology, CPT and ICD.9 and DSM codes
• Must have excellent mathematic skills to maintain and monitor batch controls and calculate payments and prepare statistical data
• Knowledge of computers, electronic data interfaces, Excel, Word, Customer Focus
• Must be meticulous and pay attention to detail
• Some college, Associates degree preferred, or 1-2 yrs. experience in Claims
• Prior Medical Claims processing (preferably in a Facets environment)
Prior Customer Service experience helpful
Title:Claims Analyst (1) Job Summary: Principle Duties and Responsibilities: Required Skills and experience: Required Education
Grade: 4
Shift: Monday – Friday 9:00am – 5:00pm
Location: 37th St
Date Posted: 11/19/07
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.
1. Analyze and adjudicate pended claims generated from Rubi Reporting System
2. Research Health Plus member file when a discrepancy exists or eligibility is questioned.
3. Analyzes claims to determine appropriate reimbursement for par and non-par providers.
4. Analyzes claims by type of service interpreting Medical and Claim Policy and Procedures
5. Reviews provider refunds and applies adjustment workflows
6. Responsible for the adjudication of complex claims for various types of service
7. Refers claims with security restrictions and/or high dollar allowable to Senior Claims Analysts
8. Interacts with providers on the telephone or by correspondence, often dealing with Doctors, Medical Office Managers, Health Officials, Hospital Billing Management, and Billing Services
9. Determines NYS member eligibility using EMEV
10. Document and track claim inquiries using Customer Focus
11. Review correspondence to determine post payment accuracy
12. Maintains all documentation for claims processing reference manuals
• 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
• Strong data entry skills (30 WPM)
• 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
High School Graduate, some college preferred
Title:currently there are no job openings at this department
Title:Enrollment Representative (2) Job Summary: Principal Duties and Responsibilities: *Essential Functions Job Specification: Required Education and Experience:
Grade: 3
Location: 37th Street
Shift: Monday – Friday 9:00am – 5:00pm
Date Posted: 4/25/08
The Enrollment Representative is responsible for assuring that all new applications for Health care Plus, Child Health Plus, Child Health Plus re-certification and Family Health Plus applications are complete and accurate.
• Reviews all new Health Plus and Child Health Plus initial applications and re-certifications for complete and accurate information.
• Reviews documents provided with the application for appropriateness in accordance with New York State guidelines.
• Batches and prepares all applications for data entry.
• Performs data entry of applications in Health Plus submission database.
• Assists the enrollment supervisor in reviewing data entry error reports.
• Verifies if applicant is Health Plus member.
• Quality checks documentation for proofs.
• Quality checks applications for completion verifying documentation for returns.
• Files application/disenrollment forms/documents for applications.
• Follows up with Representatives.
• Interacts with Member Services to resolve problems.
• Proof reads application and recerts for accuracy.
• Checks emevs for Medicaid eligibility.
• Checks and enters application for presumptives then files applications.
• Calls members to verify presumptive documents.
• Responsible for mailing out letters to remind members that documentation is due before cut-off date.
• Follows up with representatives to inform them presumptive documents are submitted on time before member is disenrolled.
• Excellent verbal and written communication skills
• Must be able to work independently with little supervision
• High School diploma or equivalent.
• Prior health care, clerical and data entry skills are necessary.
• Ability to type 40 w.p.m.
Title:Administrative Assistant Job Summary: Principle Duties and Responsibilities Required Skills: Required Education and Experience:
Grade: 3
Location: Adams St
Shift: Monday – Friday 9:00am – 5:00pm
Date Posted: 2/15/08
Provides administrative and secretarial support specifically for the Chief Medical Director and the Executive area as needed. In addition to typing, filing, and scheduling, performs duties such as record keeping, coordination of meetings and conferences, obtaining supplies, coordinating direct mailings, and working on special projects. Also, assembles highly confidential and sensitive information. Deals with the diverse group of important external callers and visitors as well as internal contacts at all levels of the organization. Independent judgment is required to plan, prioritize, organize diversified workload, and recommends changes in office practices and/or procedures.
Schedules and organizes meetings, travel, conferences and department activities for the Chief Medical Director and other members of the department as needed.
Performs desktop publishing: create and develop visual presentations
Establishes, develops, maintains and updates filing system. Retrieves information from files
When needed. Establishes, develops, maintains and updates library of trade journals and magazines.
Organizes and prioritizes large volumes of information and calls. Sorts and distributes mail. Takes messages or fields/answers all routine and non-routine questions
Acts as a liaison with other departments and outside agencies, including high-level staff such as Chiefs and Directors. Handles confidential and non-routine information and explains policies when necessary
Works independently and within a team on special nonrecurring and ongoing projects. Proofreads copy for spelling, grammar, and layout and applies appropriate changes. Responsible for accuracy and clarity of final copy
Activities include: screening phone calls, type and design general correspondence, memos, charts, tables, graphs, etc.
Must type 40 -50 WPM
Excellent command of the English language and good telephone skills
Knowledge of a variety of computer software applications in word processing, spreadsheets, database and presentation software
Must have high level of interpersonal skills to handle sensitive and confidential situations. Position continually requires demonstrated poise, tact, and diplomacy
Must be able to work with and for a group of individuals, as well as be able to prioritize work, organize tasks, and meet deadlines
Familiar with a variety of field concepts, practices, and procedures
The ability to take minutes of a meeting is preferred
Minimum 4-5 years secretarial experience, office administrative procedures or equivalent experience in a related field and use of standard office equipment
High School Diploma or GED required.
Some college or professional secretarial training preferred.
Title:currently there are no job openings at this department
Health Education & Community Outreach
Title:Community Health Education Associate (CHEA) Job Summary: Principle Duties and Responsibilities: Required Skills Required Education Preferred Experience
Grade: 3
Location: 37th Street
Shift: Monday – Friday 9:00am – 5:00pm
Date Posted: 4/25/08
Language: Assessed on an individual basis when posted
The Community Health Education Associate (CHEA) provides culturally appropriate outreach to Health Plus members for the purpose of identifying and preventing problems within the managed care environment and providing adequate and appropriate access to Primary Health Care Providers. The CHEA seeks to prevent barriers to access and care that come from lack of understanding between the member and provider or the member and the health care system.
• Provides orientation to new Health Plus members through telephonic interventions.
• Works with Medical Management on quality and utilization initiatives as assigned.
• Refers members to Health Services, Behavioral Health, Member Services and Health Education as appropriate.
• Contacts members proactively and reactively to educate to the importance of appropriate use of the health care system and establishing a relationship with the PCP. (E.g.; Prenatal, Immunization, Emergency Room, EPSDT, Well Child Visits)
• Tracks all member contact in appropriate database.
• Understands the overall benefits for Health Care Plus, Child Health Plus and Family Health Plus.
• Meets Outreach productivity standards.
• Uses proper telephone etiquette when speaking to customers
• When needed, makes home visits to members for targeted interventions
• Performs other duties as assigned or requested
• Must be able to communicate bilingually in needed languages as deemed by the department
• Must have good oral and written communication skills in both languages, and possess the ability to communicate clearly with members, colleagues and when necessary, providers.
• Must have familiarity with computers, especially word-processing and database programs.
• Must have good organizational skills.
• Must be able to work independently.
• High School Diploma or Equivalency
• At least two years experience in Health Care or Managed Care in Community Outreach preferred.
Title:currently there are no job openings at this department
Title:Supervisor Job Summary: Specific Duties and Responsibilities Required Skills Required Education and Experience
Grade: 7
Location: Adams St.
Shift: Days Monday – Friday
Date Posted: 4/25/08
The HS Supervisor is responsible for the daily oversight of the Health Services Representatives and Managed Care Clerks (MCC). Responsibilities include, but are not limited to, providing a orientation to staff, quality assurance and productivity measures, training of new staff, and continuing training of existing staff. The HS Supervisor is the direct link between the HS Representatives and the HS Managers.
• Supervises and monitors HS Representative/Managed Care Clerk staff activities to ensure success in meeting all required work processes
• Works with the Managers to enhance development of measures to assess productivity of call center
• Serves as a mentor/role model/leader to HS Representatives/MCCs
• Works with Managers to train on departmental policies and procedures
• Assist staff with understanding of medical terminology and chronic disease models of care
• Assist staff with understanding of UM, CM, and concurrent review
• Assists in QA activities as relates to customer service, appeals and denials, and surveys
• Identifies individual and group training needs for HS Representatives/MCCs, and develops one-on-one and group training programs to meet those needs
• Establishes and maintains good working relationships with providers.
• Assists in problem identification for the staff and providers
• Understands the overall programs provided by Health Plus
• Represents Managers at internal meetings as needed
• 50% of time will be spent on the Health Services queue
• Other duties as specified
• Communicates effectively in English; bilingual preferred
• Possesses strong organizational skills and is able to handle multiple tasks simultaneously
• Demonstrates computer skills with working knowledge of FACETS, Member Pro, EPACES, word processing, and spread sheets
• Demonstrates good telephone and written skills; able to communicate clearly with providers and staff
• Able to work independently, with minimal supervision
• Minimum 3 years as a Health Services Senior Representative in a managed care organization or two years supervisory experience in a managed care organization
• Must be willing and be able to work flexible hours including evenings if required
Title:Health Services Representative (5) Job Summary: Principal Duties and Responsibilities: *Essential Functions Responsible for complete data entry in computer requiring knowledge of medical terminology and basic coding terminology. • Based upon health plan policy and where applicable; Required Education and Experience:
Grade: 3
Location: Adams St.
Shift: Days Monday – Friday
Date Posted: 05/02/08
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.
• 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.
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.
• 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:Systems Administrator Job Summary: Specific Duties and Responsibilities: Required Skills: Required Education and Experience:
Grade: 8
Shift: Monday – Friday 9:00am – 5:00pm
Location: 37th St
Date Posted: 5/2/08
The Systems Administrator has responsibility to ensure the consistent operation and availability of the servers and local area network (LAN). Performs a variety of administrative and technical work under the direction of the Senior Systems Manager and Senior Systems Administrator including installing new software releases, system upgrades, evaluating and installing patches and resolving software related problems. Perform system backups and recovery. Maintains data files and monitors system configuration to ensure data integrity. Documents and develops appropriate procedure manuals and maintains documentation of server operations and projects. Helps ensure the safety, integrity and security of data stored on the network.
• Organize, set up, install, upgrade and maintain servers.
• Organize, set up, install, upgrade and maintain necessary LAN connections.
• Maintains security access to the various servers.
• Participate in the evaluation and review of new hardware and software to be installed in the network prior to acquisition.
• Participate in Disaster Recovery and Monthly Maintenance.
• Ensures the security of the Servers from external intrusions.
• Create Server documentation manuals and procedure manuals and ensure updates are performed as needed.
• Helps to maintain proper security of the computer room. Alerts management of any unsafe or potentially unsafe conditions in the computer room.
• Provide backup support for related positions as needed.
• Perform related duties as assigned.
• Ability to work independently with little supervision.
• Thorough knowledge of PC / server hardware and associated operation systems, specifically Microsoft Windows 2000 and 2003. Appropriate certifications preferred.
• Knowledge of communications equipment (ex: Switches, Routers)
• Strong knowledge of Microsoft Exchange 2000 or 2003.
• Working knowledge of client / server technologies preferred.
• Thorough knowledge of various network protocols, specifically TCP/IP.
• Thorough knowledge of Active Directory, DNS, WINS, DHCP
• Knowledge of server virtualization preferred.
• Knowledge of Citrix preferred.
• BA/BS.
• Minimum 4 years previous hands on systems administration experience in a Windows NT/2000/2003 environment.
• 8 years progressive experience in IT.
• 1 year prior managed care experience preferred.
Title:Network Administrator Job Summary: Principle Duties and Responsibilities: Job Specification: Required Education and Experience:
Grade: 9
Shift: Monday – Friday 9:00am – 5:00pm
Location: 37th Street
Date Posted: 3/07/08
General Statement: The Network Administrator has overall responsibility to ensure the consistent operation and availability of the local area network (LAN) and wide area network (WAN), including performing a variety of complex administrative and technical work in network communication installations and operations; documenting and developing appropriate procedure manuals and documentation of the LAN and WAN environment, and ensuring the safety, integrity and security of data stored on the network
• Organize, set up, install, upgrade and maintain all network communications equipment.
• Organize, set up, install, upgrade and maintain necessary LAN and WAN connections.
• Participate in the evaluation and review of new hardware and software to be installed in the network prior to acquisition.
• Ensure the security of the network from external intrusions.
• Create network documentation manuals and procedure manuals and ensure updates are performed as needed.
• Helps to maintain proper security of the computer room. Alerts management of any unsafe or potentially unsafe conditions in the computer room.
• Provide backup support for related positions as needed.
• Perform related duties as assigned.
• Ability to work independently with little supervision.
• Thorough knowledge of Cisco firewalls, routers, CSU/DSU’s, terminal servers, and their programming.
• Thorough knowledge of various network protocols, specifically TCP/IP.
• Thorough knowledge of modems, hubs and switches.
• Working knowledge of PC / server hardware and associated operation systems, specifically Microsoft Windows 2000 and 2003.
• Working knowledge of client / server technologies preferred.
• AA, AS, certificate program or equivalent. BA/BS preferred.
• 4 years of Information Systems experience.
• At least 2 years experience with Cisco router and firewall maintenance.
• Cisco certification preferred
Title:EDI Manager Job Summary: Essential Duties and Responsibilities: Required Skills: Required Education and Experience:
Grade: 9
Location: 37th St.
Shift: Monday – Friday 9:00AM – 5:00PM
Date Posted: 2/22/08
This position is responsible for managing the EDI activity of Health Plus corporate wide. This includes, overseeing the team that interacts with clearing houses, vendors, New York State and providers to ensure accurate submission and transmission as well as troubleshooting and resolving any issues with all EDI HIPAA transactions. Additional responsibilities include developing plans for improving the quality and quantity of EDI across all transactions. This would include the mapping, testing and maintenance of transactions as well as participation on corporate projects relating to any EDI HIPAA transactions.
Manages the day to day administration and support of the EDI environment and all associated electronic development projects
Primary focus will be the day to day administering of EDI operations as well as increasing the use of HIPAA Standard EDI Transactions.
Supervise and manage the EDI Staff
Monitor technical components of the system as well as tracking reports to ensure complete processing of the data.
Analyze error transactions to ascertain reasons for problems; rectify process problems and/or provide information required to make corrections.
Build and maintain positive internal and external EDI related customer related contacts. Including but not limited to Trading Partners, Providers (Facilities, Practitioners, Billing Agencies) and New York State
Maintain and monitor Enrollment and Dissenrollment files from and to Maximus
Process Billing Files for NYSDOH.
Help to develop long range EDI initiatives as well as recommend changes to current business practices to take advantage of EDI opportunities; responsible for EDI growth.
Serve as an expert on EDI and ensure that Health Plus is in compliance with all applicable HIPAA standards related to EDI.
Assist in obtaining and interpretation of HIPAA rules and regulations, development of business requirements and test cases to implement EDI transactions at Health Plus.
Implementation and maintenance of an EDI gateway and the associated translation maps. Development and enhancement of associated processes and scripts required to run and improve the process.
Serve as the liaison between Application Support Data Integration and ITS Development on all EDI related projects
Develop and implement projects that will achieve EDI and auto-adjudication goals.
Improve communications between Health Plus and customers reducing inquiries and complaints
Must have excellent verbal and written communication skills to allow for participating in the generation of project plans.
Must have solid background in ANSI X12 formats and implementation guides. Specific knowledge of 270, 271, 276, 277, 278, 820, 834, 835, 837and HIPAA standard code sets is required.
Experience with electronic commerce gateway software tools. Specific experience with Sybase/NEON/PaperFree products, ECMap, EC-Gateway and HIPAA validator products would be a big plus. Extensive knowledge of EDI systems, operations, policies and procedures.
Familiarity with various communications applications and have working knowledge of protocols such as FTP, HTTP, TCP/IP, etc.
Prior experience working in a HIPAA / Healthcare Systems environment will be useful.
General experience with Windows O/S (NT4.0, 2000), mapping tools and database technologies (SQL Server and / or Sybase) is highly desirable.
Self starter with the ability to work independently with little or no supervision. Must have good common sense.
Strong leadership, supervisory experience and excellent verbal and written communication skills.
BA/BS in Computer Science or equivalent.
At least 5 years hands on technical experience with EDI transaction processing.
Hands on experience working with transaction mapping tools.
Project Management experience preferred.
Prior managed care experience helpful.
Title:Desktop Technician Job Summary: Principle Duties and Responsibilities: Required Skills and Experience:
Grade: 6
Shift: Monday – Friday day
Location: 37th St.
Date: 2/22/08
Performs a variety of administrative and complex technical work in support of the day-to-day operation of the enterprise data communications network. Specific activities include installation and repair of PC’s, installing and upgrade of PC software, installing and testing Performs a variety of administrative and complex technical work in support of the day-to-modems and working with other network hardware as required.
Works on resolving problems and concerns of end users with their PC’s and associated hardware and software to the client’s satisfaction.
Maintains hardware and software inventory records.
May perform some limited training on hardware or software to end users.
Install PC’s and associated hardware.
Troubleshoots PC’s and associated hardware as needed.
Installs and upgrades PC software as needed.
Works with Network Administrator in trouble shooting problem area’s which may adversely affect network performance.
Provides backup support for related positions as needed.
Perform related duties as assigned
Good verbal communications skills.
Ability to work independently with little supervision.
Thorough knowledge of modems, PC hardware, peripherals and associated operating systems, specifically, Microsoft Windows 2000 and Windows XP, A+ certification preferred. Basic understanding of Macintosh hardware and operating system is desirable.
Understanding of a variety of standard office automation PC based software packages, specifically the Microsoft Office products.
Thorough knowledge of Microsoft Windows NT and Windows NT Terminal Server, Remote Desktop, Timbuktu, Symantec Ghost, Prior Citrix experience
Thorough knowledge of laser printers, specifically Hewlett-Packard and Canon Image Runners
At least 1-3 year PC Tech experience
AA/AS or certificate program. BA/BS preferred.
Title:Program Analyst (2) Job Summary: Specific Duties and Responsibilities Required Skills and Experience: Required Education and Experience
Grade: 8
Shift: Monday – Friday 9:00am – 5:00pm
Date Posted: 2/15/08
Performs a variety of skilled and technical work associated with the development and preparation of computer programs. This would include the conversation of project specifications and statements of problems and procedures. Primary focus would be on the creation and modification of computer programs.
• Works with end users and Senior Programmer / Analysts to define a business problem and design a solution for the problem.
• Works with end users and Senior Programmer / Analysts to design new workflows, systems, programs and reports to improve the operations of the organization.
• Performs some systems analysis to ensure the feasibility of proposed new programs or program modifications.
• Helps to create any documents necessary to allow end users to evaluate proposed new programs or program modifications.
• Primary responsibility will be to develop software code as needed.
• Help to generate test plans to allow thorough testing of new programs or program modifications.
• Participate in the creation of necessary documentation, including end user documentation, procedure manuals and associated run sheets.
• Assist in developing any training materials that will be needed as part of the implementation process and participate in the delivery of training.
• Perform related duties as assigned.
• Must have excellent verbal and written communication skills to allow for participating in the generation of design documents.
• Should have experience in understanding both hardware and software applications.
• Excellent programming and analysis skills.
• At least 2 years experience as a Junior Programmer / Analyst.
• Prior managed care experience helpful
• AA/AS in Computer Science or equivalent. BA/BS preferred.
Title:Project Manager Job Summary: Specific Duties and Responsibilities Required Skills: Required Education and Experience:
Grade: 10
Location: 37th St
Shift: Monday – Friday Days
Date Posted: 1/14/08
Performs a variety of skilled and technical work associated with the development and preparation of computer programs. This would include the conversation of project specifications and statements of problems and procedures. Primary focus would be working with the applications development staff to develop project plans and monitor progress of the projects.
• Works with the development staff and end users to develop a project plan based on the needs of the organization as well as the resources that will be required.
• Analyzes and aides with supervision of systems and programming projects which include both managerial and project task level activities.
• Develops and mains a productive working relationship with project sponsors and key systems users; helps in prioritizing new development projects.
• Estimates staff resource needs for programmer / analysts, user personnel, consultants and other resources; helps with the development of team member work assignments and schedules, guides and monitors work performance.
• Helps to ensure that assigned areas of responsibility are performed within budget; assures efficient use of personnel resources as well as facilities and time.
• Help to generate test plans to allow thorough testing of new programs or program modifications.
• Participate in the creation of necessary documentation, including end user documentation, procedure manuals and associated run sheets.
• May assist in developing any training materials that will be needed as part of the implementation process and participate in the delivery of training.
• Helps in the development of project budgets.
• Perform related duties as assigned.
1. Must have excellent verbal and written communication skills to allow for participating in the generation of project plans.
2. Must have solid background in formal project management.
3. Experience with project management software.
1. AA/AS in Computer Science or equivalent. BA/BS preferred.
2. At least 2 years experience as a project manager in a systems environment.
3. Prior managed care experience helpful.
Title:Field Marketing Supervisor Job Summary: Principle Duties and Responsibilities: Required Skills and experience: Required Education:
Grade: 7
Shift: Variable Schedule/Hours
Location: Brooklyn South
Date Posted: 3/07/08
Under the direct supervision of the Marketing Manager, 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.
• 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, Adobe PhotoShop.
• Associates degree in Communication, Marketing or related education.
• Minimum three to five years of supervisory experience. Experience in the Health industry preferred.
• Valid driver’s license.
• Flexible work schedule.
Title:Marketing Representatives(8) Bronx (2) Queens North (1) 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 three 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. Required Skills: Required Education and Experience:
Grade: 3
Location: Asian Team (1)
English/Cantonese/Mandarin
Brooklyn North (1)
English/Spanish
Brooklyn South (2)
English /Second Language
Manhattan (2)
English/Spanish
No Second Language
Shift: Variable days and variable hours. You will need to be available to work some weekend and
holidays.
Date Posted: 2/22/08
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.
High School diploma or G.E.D required. Health care and some marketing, sales and/or customer services experience preferred.
Second language skills a plus.
Clean, valid drivers license and car a plus.
Marketing Business Development
Title:currently there are no job openings at this department
Title:currently there are no job openings at this department
Title:Quality Control Coordinator Principal Duties and Responsibilities: * Essential Functions Job Specifications: Required Education and Experience:
Grade: 5
Location: 37th Street
Shift: Variable
Date Posted: 4/25/08
• Monitors and reviews members’ calls utilizing a standard quality monitoring tool.
• Ensures success in meeting deadlines including daily monitoring of calls.
• Assists in the identification of individual& group instructional needs for Recertification Representatives & works with the management team and training to development one – on – one & group guidance programs to meet those needs.
• Monitors incoming CHP & FHP applications to ensure completeness. Tracks & monitors errors & incomplete applications for trends.
• Identifies areas of improvement for Recertification Representatives, reviews internal audit reports for quality performance measures and guidance of Recertification Representatives
• Works with supervisor to ensure Representatives maintain pre-determined departmental production levels.
• Provides management team with reports regarding performance trends.
• Assists in the development of the Quality Improvement Program for the department.
• Understands the overall eligibility requirements for Medicaid, Health Care Plus, Family Health Plus and Child Health Plus.
• Presents to the management team all production problems and takes prompt corrective action when necessary to resolve processing issues.
• Other duties and responsibilities as assigned.
• Possesses strong organizational skills and is able to multi-task.
• Must be self motivated & able to work independently with minimal supervision.
• Must be willing and able to work in a multi-ethnic environment.
• Must present an appearance and demeanor consistent with Health Plus’ professional image.
• Must have working knowledge (intermediate level) of the Microsoft Office Suite and other Health Plus applications and desktop programs.
• High School diploma or GED required
• A minimum of two (2) years of customer service experience required.
Title:Retention Representative (3) Job Summary: Principal Duties and Responsibilities: Job Specification: Required Education and Experience:
Grade: 3
Location: 37th St.
Language: English/Spanish
Shift: Variable days and Variable Hours
Date: 4/25/08
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.
• Calls 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.
• 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.
• High School diploma or GED required.
Title:Marketing Assistant Job Summary: Principal Duties and Responsibilities: *Essential Functions Required Education and Experience:
Grade: 3
Location: 37th St
Shift: Monday – Friday 9:00AM – 5:00PM
Date Posted: 2/29/08
The Marketing Assistant is responsible for assuring that all new applications for Health Care Plus, Child Health Plus, and Child Health Plus recertification applications are complete and accurate.
• Follows-up by phone or by letter to acquire missing documentation, payment for Child Health Plus application, or missing Medicaid numbers for Health Care Plus application, completion of personal questionnaire.
• Keeps a record of the number of applications taken in each program, tracks their source, and reports this information to the Marketing Manager on a weekly basis.
• Coordinates event logs.
• Sends out contracts and customer copies of the Child Health Plus applications.
• Assists the Special Events Coordinator in preparing for upcoming events.
• Prepares time cards and schedules along with Marketing Manager.
• Prepares overtime reports along with Marketing Manager.
• Prepares agendas for weekly meeting between Marketing Manager and Marketing Representatives.
• Manages Marketing Manager’s calendar.
• Sets up presentation packages as needed.
• Tracks supplies and requests supplies for marketing sites.
• Keeps track of applications returned to Marketing Representatives.
• Assists with the preparation for the Articles 44 audit which occurs every 2 years.
• Other duties as assigned by Marketing Manager.
• High School diploma or equivalent (G.E.D.) required.
• Health care, clerical, and some marketing experience 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
Title:Senior PRA – Contracting Job Summary: Specific Duties and Responsibilities Required Skills Required Education and Experience
Grade: 7
Shift: Monday – Friday 9:00am – 5:00pm
Location: Adams St
Date Posted: 04/25/08
Under the overall direction of the Contracts Implementation Manager, the Business Analyst will assist the Sr. Business Analyst and Sr. Contract Implementation Analyst in the overall contracting implementation and auditing process for ensuring governmental compliance of all existing contracts and templates.
• Provide analytical support to the Provider Relations & Network Management Dept. in the auditing of network contracts to ensure that contracted arrangements are within compliance of Health Plus practice and standards.
• Assist in the tracking of all applicable contracts, amendments, and templates to the NYSDOH and/or SID.
• Assist in maintaining the department’s reimbursement template to use as an auditing tool to ensure payment arrangements are being processed by the Claims Dept.
• Assist in preparing concise documentation and audit reports including recommendations for improvement to the Manager of Contract implementation. Follow-up on recommendations to ensure implementation is required.
• Assist in maintaining the accuracy of the Contract Implementation Database
• Assist the Sr. PSR in investigating and resolving provider inquiries and complaints
• Assist the Sr. PSR in investigating and resolving intra- and interdepartmental contracting inquiries
• Other activities and duties as assigned by the Contract Implementation Manager (policy research, training classes, etc.)
• Working knowledge of managed care concepts and health care delivery
• Must have excellent written and oral communication skills
• Must be able to work with people at all levels within and outside the organization
• Ability to work independently and in a team setting
• Must know Microsoft Office Suite (Word, Excel, Access, PowerPoint, and Outlook)
• Must be detail-oriented
• Ability to occasionally work over-time as required
• B.A. or B.S. degree, health related field preferable
• One to two years in health care delivery or managed care with at least one year experience in the contracts, provider relations and/or claims area.
Title:Provider Relations Associate –CI (2) Job Summary: Specific Duties and Responsibilities: Required Skills: Required Education and Experience
Grade: 6
Shift: Monday – Friday 9:00am – 5:00pm
Location: Adams St
Date Posted: 3/21/08
Under the overall direction of the Contracts Implementation Manager, the Senior PSR assists in the overall contracting implementation and auditing process for ensuring governmental compliance of all existing contracts and templates.
• Provide analytical support to the Provider Relations & Network Management Dept. in the auditing of network contracts to ensure that contracted arrangements are within compliance of Health Plus practice and standards.
• Assist in the tracking of all applicable contracts, amendments, and templates to the NYSDOH and/or SID.
• Establish and maintain a reimbursement template to use as an auditing tool to ensure payment arrangements are being processed by the Claims Dept.
• Assist Contracting Dept. in preparing the financial analysis of reimbursement proposals for new and existing contracts.
• Coordinate implementation process of new contracts.
• Maintain the accuracy of the Contract Implementation Database
• Assist in investigating and resolving provider inquiries and complaints
• Assist in investigating and resolving intra- and interdepartmental contracting inquiries
• Assist in monitoring the timeliness of claims processing for contracted vendors, including the resolution of NYSDOH and/or SID audits, and other audits to ensure compliance with contractual mandates as specified by the Contracts Implementation Manager.
• Other activities and duties as assigned by the Contract Implementation Manager (policy research, training classes, etc.)
• Working knowledge of managed care concepts and health care delivery
• Familiarity with contracts, specifically managed care contracting language and reimbursement methodologies
• Must have excellent written and oral communication skills
• Must be able to work with people at all levels within and outside the organization
• Ability to work independently and in a team setting
• Must know Microsoft Office Suite (Word, Excel, Access, PowerPoint, and Outlook)
• Must be detail-oriented
• Ability to occasionally work over-time as required
• B.A. or B.S. degree, Master degree preferred, health related field preferable
• Three years experience in health care delivery or managed care with at least one year experience in a managed care organization, contracts and/or claims area preferable.
Title:Senior Provider Service Analyst Job Summary: Specific Duties and Responsibilities Required Skills Required Education and Experience
Grade:
Shift: Monday – Friday 9:00am – 5:00pm
Location: Adams St.
Date Posted: 3/21/08
Under the overall direction of the Associate Director of Provider Services and under the direct supervision of the Provider Services Supervisor, the Senior Provider Service Analyst is a professional who is responsible for researching and analyzing all provider service issues particularly related to provider data and reimbursement, and resolving provider issues in a timely manner to ensure compliance with Health Plus & government guidelines, and to improve provider satisfaction.
• Handles and resolve provider issues/complaints in a timely manner
• Handles and resolve pended claims issues related to provider selections/configuration issues in compliance with government and Health Plus guidelines
• Handles and research all complex/large claims files from providers
• Interpret claims, provider contracts & their configuration to ensure accuracy in provider set-up and their reimbursement
• Produces analysis, reports, recommendations and action plans to resolve provider/network issues in a timely manner
• Identifies and tracks provider issues, system problems/deficiencies, and refers frequent issues to management
• Researches and identifies trends, and develops methods to improve results and processes
• Produces business requirements, prepares detailed descriptions of provider configuration/system issues, proposed enhancements and major changes
• Provides statistical analysis for producing area measures
• Works in collaboration with different areas in Provider Relations, Claims and ITS to ensure provider issues are being resolved in a timely fashion
• Establishes and maintains good working relationship with providers
• If necessary, represents the team in meetings with Provider Relations staff and providers to resolve provider data/reimbursement issues
• Supports ITS in testing to implement system upgrades and new systems/policies & procedures
• Other activities and duties as assigned by Provider Relations Management
• Must be self-motivated and able to work autonomously
• Must be a leader who can drive resolution and provide on-going feed back and make recommendations when needed in a timely manner
• Must be highly organized, detail oriented and able to act with a sense of urgency to research questions or issues brought by the team
• Must have excellent communication skills (verbal and written), work effectively independently as well as with a team
• Must have excellent interpersonal skills and be able to work with providers and provider’s staff in a professional manner
• Ability to lead multiple projects
• Must have knowledge of medical terminology, managed care contracting, reimbursement methodologies, and working experience in claims processing details (medical & hospital)
• Must understand Health Plus’ contracts, provider system configurations, and reimbursement policies & processes
• Must know Microsoft Office, and have working experience with database management programs (Excel & Access)
• BA/Bachelor Degree or equivalent experience in:
• Three years experience regarding claims processing/analysis and
• Three years experience at Health Plus in handling and resolving provider
Title:Quality Control Supervisor Credentialing Job Summary: Principal Duties and Responsibilities: *Essential Functions Job Specification: Required Education and Experience:
Grade: 7
Shift: Monday – Friday 9:00am – 5:00pm
Location: Adams Street
Date Posted: 3/7/08
Under the general direction of the Provider Relations Operations Manager, Quality Control Supervisor is responsible for the daily oversight all data processing staff (Managed Care Clerks, Data Specialists, and Quality/System Specialists). Responsibilities include, but are not limited to, staff training, task assignment, monitoring of work quality and productivity level. The Supervisor is the direct link between the data processing staff and all other areas of the organization as well as providers and vendors.
• Coordinates and oversees the Data Center staff’s daily activities to ensure all provider data is entered accurately and in a timely manner.
• Understands Health Plus’ overall provider contracts, network set up, and configurations.
• Closely coordinates with Provider Relations Associates & Managers regarding accuracy of payment arrangements and other data as necessary, prior to approval for entry into systems.
• Coordinates with IT/Model Office for troubleshooting and system modifications/upgrades.
• Coordinates with IT/Model Office to ensure accuracy and smooth transition of all data.
• Answers questions and assists claims staff on the daily functions of the area conversions.
• Review monthly capitation batch as required by IT
• Reviews (or serves as back-up) on-going XPF batch process to confirm that data is flowing correctly from Legacy to Facets (for claims payment.)
• Develop reports and audit tools with Quality/System Specialists to ensure data accuracy in compliance with Health Plus’s standards.
• Interprets provider set up and Health Plus’ policy and procedures as needed to staff
• Insures implementation of Provider Relations policy and procedures and suggests changes as needed.
• Prepares monthly statistical summaries, communicates data processing activities to the management
• Coaches and trains new and existing Data Center staff
• Identifies system problems and suggests needs for modifications
• Must be able to exercise independent judgment
• Excellent verbal, written and presentational skills
• Excellent organizational skills
• Ability to maintain a professional rapport with support staff and upper management
• Ability to comply with changing regulations and work flow environments at Health Plus
• Knowledge of computers, electronic data interfaces, Excel and Word
• Must be meticulous and pay attention to detail
• Bachelor’s degree preferred
• At least three years managed care experience required;
• One year of supervisory experience preferred;
• Must be willing and be able to work flexible hours including evenings if required.
Title:Provider Relations Associate Job Summary: Principal Duties and Responsibilities: *Essential Functions Required Skills: Required Education and Experience:
Grade: 6
Location: Manhattan (1)
Shift: Monday – Friday 9:00am – 5:00pm
Date Posted: 11/30/07
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.
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
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
B.A. or B.S. degree required
Three years experience in health care delivery or insurance with at least one year experience in a managed care organization
Title:Quality & Systems Specialist Job Summary: Principal Duties and Responsibilities: *Essential Functions Required Skills: Required Education and Experience:
Grade: 6
Location: Adams St.
Shift: Monday – Friday 9:00am – 5:00pm
Date Posted: 2/01/08
Under the overall direction of the Senior Manger of Provider Relations Operations, the Quality System Specialist has overall responsibilities for training, auditing and facilitating Continual Process Improvement in the Data Center. The Quality Specialist will work with management staff to develop a comprehensive audit process and conduct auditing as prescribed. She/he will also assist in training all data center staff.
Assists management in facilitating, coordinating and delivering training programs for new and existing data center staff
Assists management in developing, maintaining all documentation including workflow, policies and procedures, and training materials
Audits all data entries and report results to management
Documents staff performance against standards
Assists in the ongoing evaluation of policies and procedures, and the development and implementation of new performance standards
Assists department with staffing deficiencies, as required, by providing temporary assistance
Interprets complex provider contracts, policy and procedures to facilitate provider set-up in systems
Supports ITS in testing to implement system upgrades and new systems
Function as Subject Matter Expert in Facets and Cactus
Other activities and duties as assigned by the Provider Relations Management
Must be self-motivated and able to work independently
Must be able to work with people at all levels within the organization and facilitate work group processes
Demonstrated proficiency in all other provider systems
Must have knowledge of product benefits, provider contracts
Must have knowledge of medical terminology, fee reimbursement, and claims processing
Must know Microsoft Word for Windows and must have good spreadsheet application skills.
Must be able to navigate in a multi-system environment
Experience with database management programs is a plus
Detail Oriented
Excellent documentation skills
B.A. or B.S. degree
One year experience in a managed care organization required, preferably in Provider Services
Title:Credentialing Specialist Job Summary: Job Specification: Required Education and Experience:
Grade: 3
Location: Adams Street
Shift: Monday – Friday 9:00am – 5:00pm
Date Posted: 2/8/08
The Credentialing Specialist, under the direction of the Provider Communications and Credentialing Coordinator, is responsible for ensuring that all new applications to be a HEALTH PLUS provider are processed in a timely manner and for ensuring that all credentialing files are maintained to meet NCQA and NYSDOH standards.
• Must be able to work with people at all levels within the organization
• Must have excellent interpersonal skills and be able to work with providers and provider staff
• Must have good written and oral communication skills
• Must know WordPerfect or Microsoft Word for Windows
• Must be willing to take classes in applicable Health Plus applications
• Must be Knowledgeable in database management and internet research
• Detail oriented required
Minimum of Associate Degree (AAS), or 2 years of relevant experience. Relevant experience in credentialing and maintaining/handling provider data is preferred
Title:Credentialing Coordinator Job Summary: Specific Duties and Responsibilities: Required Skills: Required Education and Experience:
Grade:
Location: Adams Street
Shift: Monday – Friday 9:00am – 5:00pm
Date Posted: 2/8/08
The Credentialing Coordinator, under the direction of the Senior Manager of Provider Relations Operations, is responsible for credentialing and re-credentialing of providers, maintenance of provider charts, submission of the Health Plus provider network to NYSDOH in compliance with NCQA and NYSDOH standards and timelines.
• Responsible for implementing Health Plus credentialing program in compliance with NCQA and NYSDOH standards and timelines
• Ensures all provider applications to be credentialed/re-credentialed as a HEALTH PLUS participating providers in a timely manner
• Responsible for reviewing each provider file and making a recommendation to the Medical Director as to credentialing each new provider
• Continuously reviews the Health Plus provider database for accuracy and completeness and it is accurate for Health Provider Network submission to NYSDOH
• Overseas all credentialing on-site audits for delegated credentialing entities
• Oversees all organizational providers set-up
• Responsible for developing, maintaining all credentialing manual, and other documentation including audit processes, workflows, and training materials
• Trains, coaches and develop new and existing credentialing staff
• Complete performance evaluations
• Makes recommendations regarding hiring / termination
• Assists in training, coaching and evaluating Credentialing Specialists
• Identifies potential (system / process related) issues, and facilitates continual process improvement in credentialing area
• Supports ITS in testing to implement system upgrades and new systems
• Performs quality audits on all provider setup in systems to ensure correct contractual agreements
• Other activities and duties as assigned by the Senior Manager of Provider Relations Operations and Director of Provider Relations and Network Development
• Must be self-motivated and able to work independently
• 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 in a professional manner
• Knowledge of medical terminology preferred
• Must know Microsoft Word for Windows and must have good spreadsheet application skills.
• Willing to take classes in applicable Health Plus application
• Detailed Oriented
• BA or BS Degree preferred, Associate Degree required
• Three years experience working for a managed care organization with at least two years experience in credentialing
• NAMSS Certification preferred
Title:Senior Provider Relations Associate (1) Job Summary: Duties: Required Skills/Education and Experience:
Grade:
Location: Adams Street
Shift: Monday – Friday 9:00am – 5:00pm
Date Posted: 04/25/08
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.
• Prepares financial analysis of reimbursement proposals for new and existing contracts
• Prepares analysis on language requests when negotiating or renegotiating contracts
• Assists Contract Manager in effectively negotiating contracts
• Upon finalization of negotiations, prepare final contracts for provider signature, draft amendments to contracts and conducts follow-up and tracking as needed
• Coordinates implementation process of new contracts
• Prepares summary of contracts for the purpose of appropriate system configuration
• Monitors behavioral health and ancillary network growth and recruitment needs
• Working Knowledge of managed care concepts and health care delivery
• Familiarity with contracts, specifically managed care contracting language and reimbursement methodologies
• B.A. or B.S. degree, Masters degree preferred, health related field preferable
• Three years experience in health care delivery or managed care with at least two years experience in a managed care organization, contracts area preferable
Title:Senior Data Analyst Job Summary: Principal Duties and Responsibilities: *Essential Functions Job Specification: Required Education and Experience:
Grade: 7
Location: Adams St
Shift: Monday – Friday 9:00am – 5:00pm
Date Posted: 9/21/07
Under the overall direction of the Senior Manager of Provider Relations Operations, the Senior Data Analyst is responsible for providing and coordinating technical and operational supports to Provider Relations and Network Development Department.
Assists management in designing reports in monitoring network adequacy; ensures the timeliness and completeness of the reporting generation and distribution. They include:
Network Assessment Map Report
Provider Capacity Report
Network Growth Report
In conjunction with IT, and other Provider Relations areas, responsible for integrity of HEALTH PLUS Provider database and other provider listings (e.g. provider contact listings)
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)
• Oversees and supports GeoAccess Enterprise Directory System
• Acts as a liaison between IT and PR to develop the enterprise reporting application
• Designs and develops reports to support all reporting needs in PR areas
• Trains, coaches and develops new data analyst(s)
• Assists in developing and evaluating data analyst(s)
• Makes recommendations regarding hiring/termination
• Other activities and duties as assigned by the senior Manager of Provider Relations Operations and the Director of Network Management and Provider Relations.
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 project management experience
Must have excellent computer skills. Mastery in Microsoft Excel and Access for Windows, and GeoAccess applications. Experience in a page layout application and other database management programs is highly desirable.
Must be willing to take classes in applicable HEALTH PLUS applications.
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 project management experience
Must have excellent computer skills. Mastery in Microsoft Excel and Access for Windows, and GeoAccess applications. Experience in a page layout application and other database management programs is highly desirable.
Must be willing to take classes in applicable Health Plus applications
Title:Quality Improvement Coordinator Job Summary: Specific Duties and Responsibilities
Grade: 8
Location: Adams St.
Shift: Monday – Friday 9:00am – 5:00pm
Date Posted: 3/21/08
The Quality Care Coordinator is a staff position that, in conjunction with the Director of Quality Improvement and the Quality Improvement Supervisor is responsible for assessment of clinical management and the implementation of Quality Improvement studies in provider’s offices and centers of care throughout the Health Plus network
• In conjunction with the Director of Quality Improvement, the Quality Improvement Supervisor and the Chief Medical Officer designs Quality Improvement studies
• Responsible for the implementation of Quality Improvement studies throughout the network
• Responsible for completing the primary care provider medical record review for recredentialing
• Conducts medical record reviews
• Responsible for the identification of specific Quality of Care issues and trends in Quality Issues found in medical record review
• Monitors Quality of Care in the inpatient hospital center using clinical indicators to identify, track and trend sentinel events.
• Responsible for assessing the coordination of care provided by primary care providers
• Reports finding to the Director of Quality Improvement, the Quality Improvement Supervisor, the Chief Medical Officer, and the Quality Improvement Committee
• Collects, analyzes and displays data used in the Quality Improvement process
• Monitors clinical quality indicators
• Reviews all sources of input (e.g., complaints, member satisfaction surveys, utilization management reports, and feedback from providers, marketing and member services staff) to identify problems or potential problems for Quality Improvement intervention
• Tracks and monitors corrective action plans
o Provides support to the HEALTH PLUS Director of Quality Improvement Manager, the Qu