<h3>Job Description</h3>
Job DescriptionAbout us: 
Solis Health Plans is a new kind of Medicare Advantage Company. We provide solutions that are more transparent, connected, and effective for both our members and providers. Solis was born out of a desire to provide a more personal experience throughout all levels of the healthcare journey. Our team consists of expert individuals that take pride in delivering quality service. We believe in a culture that collaborates and supports one another, and where success is interlinked, and each employee is valued. Please check out our company website at <a href="http://www.solishealthplans.com" target="_blank">www.solishealthplans.com</a> to learn more about us!
 
Position is FULLY ON SITE Monday-Friday.
Location: 9250 NW 36th St, Miami, FL 33178.
 
*Must be Bilingual in English and Spanish.*
 
Full benefits package offered on the first on the month following date of hire including: Medical, Dental, Vision, 401K plan with a 100% company match!
Our company has doubled size and we have experienced exponential growth in membership from 2,000 members to over 10,000 members!
Join our winning Solis Team! 
 
Position Summary:
 
Solis Health Plans is looking for a Member Services Representative primarily responsible for providing quality, professional service to all customers when calls are received through the Member Services Department via telephone, written or in-person in accordance with Plan guidelines.
 
Essential Duties and Responsibilities:
<ul>
<li>Handles telephone, written and in-person inquiries in a courteous, professional, thorough, and timely manner to assure member satisfaction.</li>
<li>Assists callers on inquiries regarding coverage decisions, grievances, appeals, benefit interpretation, eligibility verification, medical group/PCP, explanation of how the plan works and how to utilize services, assists with information regarding referrals or authorizations, member complaints, identification card requests.</li>
<li>Must Report to the Doral HQ.</li>
<li>Responsible for maintaining customer service levels (abandonment rate, speed of answer and service level) within established parameters.</li>
<li>Is knowledgeable on plans benefit, CMS and Plans policies and procedure.</li>
<li>Applies high level of subject matter knowledge to solve a variety of common business issues.</li>
<li>Provides quality services effectively to increase the overall level of customer service and satisfaction as measured by CMS.</li>
<li>Identifies the differences between a Grievance, Appeal or Coverage Decision and process the request through the appropriate channels.</li>
<li>Identify, handle, document and/or route Utilization Management inquiries appropriately</li>
<li>Identify and document Coverage Determinations.</li>
<li>Documents all inquiries and complaints.</li>
<li>Interacts with other departments about member issues or concerns.</li>
<li>Approaches work in a meticulous and thorough manner, pays attention to detail and follows company scripts.</li>
<li>Manages time effectively and prioritizes tasks to meet deadlines.</li>
<li>Assists customers, family members and others with concern and empathy; respect their confidentiality and privacy and communicate with them in a courteous and respectful manner.</li>
<li>Complies with company policies and procedures and maintains confidentiality of customer medical records in accordance with state and federal laws.</li>
<li>Ensures compliance with all HIPAA, OSHA, and other federal, state and local regulations.</li>
<li>Participates in meetings, trainings and in-service education, as required.</li>
<li>Highly regulated environment.</li>
<li>Time frames to handle issues are in accordance with CMS time frames.</li>
<li>Interacts with members, family members, staff, visitors, government agencies, etc., under a variety of conditions and circumstances.</li>
</ul>
Qualification and Education:
<ul>
<li>Minimum of High School diploma or equivalent.</li>
<li>Minimum of 1year healthcare experience is required, with a preference for plan experience.</li>
<li>Working knowledge of the Privacy and Security Health Insurance Portability and Accountability Act (HIPAA) regulations.</li>
<li>Excellent communication skills, attention to detail, ability to set priorities appropriately and meet strict deadlines and the ability to manage multiple tasks simultaneously is required.</li>
<li>Excellent listening, interpersonal, verbal and written communication skills with individuals at all levels of the organization.</li>
<li>Excellent computer knowledge is required, including proficient knowledge of Microsoft Office</li>
<li>Familiarity with healthcare laws, regulations and standards.</li>
<li>Ability to compute basic arithmetic and work with numbers.</li>
<li>Must be patient in dealing with an elderly population and sympathetic to hearing or vision deficiencies.</li>
<li>Ability to work effectively independently, work with very little supervision and in a team environment.</li>
<li>Ability to read, analyze, and interpret technical procedures or governmental regulations.</li>
<li>Ability to effectively present information and respond to questions from groups of managers, clients, customers and the general public.</li>
<li>Ability to define problems, collect data, establish facts, and draw valid conclusions.</li>
<li>Strong decision-making, analytical skills.</li>
<li>Must be self-motivated, organized and have excellent prioritization skills.</li>
<li>Must be able to work well under stressful conditions.</li>
<li>Must be able to work in a fast paced environment.</li>
<li>Fluency in English and Spanish.</li>
</ul>
 
What set us apart:
Join Solis Health Plans as a Member Services Representative (Bilingual) and become a catalyst for positive change in the lives of our members. At Solis, you will be part of a locally rooted organization deeply committed to understanding and serving our communities. If you are eager to embark on a purpose-driven career that promises growth and the chance to make a significant impact, we encourage you to explore the opportunities available at Solis Health Plans. Join us and be the difference!

Member Services Representative

<h3>Job Description</h3>
Job Description
Association Representative/Labor Relations
San Jose, California: San Francisco Bay Area
RNPA (Registered Nurses Professional Association)
RNPA is a small local nurses’ union that represents more than 3,500 Registered Nurses within Santa Clara County. We’ve been independent for more than 42 years, and all our Board of Directors are Registered Nurses who work alongside their membership. We have members spread throughout the Santa Clara Valley Health and Hospital System, which includes St. Louise Regional Hospital, O’Connor Hospital, Clinics, and Custody Health.
This is a full journey level salaried exempt position. This position is responsible for providing the full range of union representation for RNPA members, including but not limited to labor management, contract negotiations and enforcement, grievance handling, member organizing, research, disciplinary representation, dispute resolution, training, and implementation.
DUTIES:
· Works independently and in collaboration with Senior Association Representative to process grievances and appeals
· Assists with member inquiries by phone, email, or in person
· Assists members with the resolution of personnel issues encountered in the workplace
· Serves as support staff to the negotiating team, taskforces, and committees
· Assists in the distribution of newsbreaks, leaflets, bulletins notices, email updates and/or any other pertinent association material to the membership worksite(s)
· Conducts surveys, audits, investigations, and related research to aid in the development of union policies, bargaining positions and future interests
· Attends meetings to represent RNPA members as assigned
· Serves as a liaison to community and labor groups as needed
· Assist with the organizing membership which includes development, planning and implementation of RNPA member activities and events
MINIMUM QUALIFICATIONS
Requirements:
<ul>
<li>Proven ability to organize and plan work</li>
<li>Leadership skills to educate, motivate, and organize members</li>
<li>Ability to manage multiple tasks simultaneously while being flexible</li>
<li>Ability to exercise sound judgment in complex situations</li>
<li>Strong public speaking skills</li>
<li>Knowledge of or ability to acquire computer skills</li>
</ul>
· Driver’s License and auto insurance
· Willingness to work flexible hours if needed including evenings
· Ability to communicate effectively orally, and in writing to a variety of individuals and groups.
· Analytical skills directed toward investigation, planning, and preparation
· Ability to establish and maintain rapport with our diverse membership and multi-cultural community groups
· Ability to work under time guidelines with minimal supervision
· Ability to take direction from the leadership team as needed and strives to meet the mission statement and objectives of the Association.
Preferred Qualifications/Experience
· Salesforce
· Human Resources
<ul>
<li>College degree in labor-related field; or extensive experience and demonstrated ability in labor relations, labor organizing or related work</li>
</ul>
· Contract Negotiations
· Labor Organizing
· Experience and knowledge working with healthcare professionals
· Knowledge about small businesses and local independent unions
SALARY
Competitive salary structure and excellent benefit package, to be determined at the time of employment. Offer is commensurate with education and experience.
To Apply:
 Fax or email cover letter and résumé to <a href="mailto:RNEXEC@rnpa.net" target="_blank">RNEXEC@rnpa.net</a> or contact office at (408) 292-6061
Company DescriptionRegistered Nurse Professional Association (RNPA) was founded in 1978. RNPA is an independent organization representing registered nurses working for the County of Santa Clara. We have 3,500 members working throughout the Santa Clara Valley Health and Hospital System. Our members work at Valley Medical Center, O’Connor Hospital, Saint Louise Regional Hospital, Ambulatory and Community Health Services, Psychiatric Services, and Custody Health Services. We are looking for energetic, hard-working professional staff who is committed to representing registered nurses. 
<h3>Company Description</h3>
Registered Nurse Professional Association (RNPA) was founded in 1978. RNPA is an independent organization representing registered nurses working for the County of Santa Clara. We have 3,500 members working throughout the Santa Clara Valley Health and Hospital System. Our members work at Valley Medical Center, O’Connor Hospital, Saint Louise Regional Hospital, Ambulatory and Community Health Services, Psychiatric Services, and Custody Health Services. We are looking for energetic, hard-working professional staff who is committed to representing registered nurses.

Association Representative/Labor Relations

<h3>Job Description</h3>
Job Description
Job description
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following: Assists Members in administrative investigations and hearings, disciplinary and grievance matters, Criminal, Civil and other labor/employment cases. Gathers evidence in administrative discipline, civil, criminal, and other cases to formulate defense or to initiate legal action. Conducts research, interviews clients, and witnesses and handles other details in preparation for trial or hearing. Prepares APPEALS, legal briefs, develops strategy, arguments and testimony in preparation for presentation of case. Files legal documents with court clerk. Represents client in court, and before quasi-judicial or administrative agencies of government. Interprets laws, rulings, and regulations for individual members and local associations. Drafts and/or reviews legal documents Assists Members in the preparation, review and signing of Will documents. Advises local associations concerning transactions of business involving internal affairs, directors, officers and corporate relations with general public. Respond to Critical Incidents by appropriate CIRT protocols. Serves on rotating basis for critical incident "on call" duties. Travel to other regions in Texas to represent members or other interests of CLEAT, as needed or as directed by supervisory personnel.
SUPERVISORY RESPONSIBILIITIES This job has no supervisory responsibilities.
QUALIFICATIONS To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE Juris doctorate from an accredited law school. 3+ years’ experience preferred for this position.
LANGUAGE SKILLS Ability to read, analyze, and interpret the most complex documents. Ability to respond effectively to the most sensitive inquiries or complaints, in person, or hearings. Ability to make persuasive arguments and articulate on controversial or complex topics to top management, public groups, governmental bodies, arbitrators, and/or courts of law.
REASONING ABILITY The ability to apply principles of logical and deductive reasoning skills necessary for creative thinking and strategic problem solving.
CERTIFICATES, LICENSES, REGISTRATIONS Juris doctorate from an accredited law school. Current bar license from State Bar of Texas. A valid Texas driver’s license, to operate a motor vehicle currently registered and inspected.
PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this Job, the employee is regularly required to speak and listen in order to effectively communicate. The employee is frequently required to sit for hours at a time. The employee is occasionally required to stand; walk and reach with hands and arms. The employee must regularly lift and /or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision and ability to adjust focus. Operate a motor vehicle in many different weather conditions and, environments as well as drive day or night.
WORK ENVIRONMENT The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Some travel required; some overnight stay required on CLEAT business to include cases that are not local, arbitrations, court cases and continuing legal education. Office environment is 1-3 attorneys, and possibly others. The noise level in the work environment is usually moderate.
COMPUTER SKILLS To perform this job successfully, an individual should have working knowledge of Zoom, TEAMS, Outlook, Word, and TxDocs/Prodoc, and Westlaw and/or LexisNexis as well as other word processing software. Proficient in using the CLEAT on-line membership database to confirm membership benefits.
Job Type: Full-time Pay: Starting From $80,000.00 per year + Benefits
Company DescriptionThe Combined Law Enforcement Associations of Texas, or CLEAT, was born during the mid-1970’s by innovative police officers seeking to enhance the law enforcement profession. CLEAT’s rich history begins with rank and file officers not being represented. The organization began by separating itself from a do-nothing, pro-management organization that refused to represent its members. Many of the founders were returning veterans of the Vietnam War era and were unhappy with the way their statewide police association’s (TMPA) refusal to hire attorneys or represent members when they were disciplined, demoted or terminated. Like our nation’s founders, these officers met with the leaders of TMPA and attempted to change the organization from within. The officers aired their grievances about how things were being handled and after seeing zero change, year after year, these officers began asking one another why they couldn’t just form their own union that would actually represent street cops and get things done in a state that no longer fit the mold of the largely rural, good ole boy, pro-management state-wide association that had failed them badly. After a dramatic walkout of the annual convention, the officers banded together, created a real union for working officers and never looked back. At every milestone, the naysayers predicted CLEAT and its leaders would fail. But CLEAT leaders and members forged ahead, lending of themselves, their lives and futures in order to build an organization that worked for all officers. As a law enforcement professional your job is difficult, dangerous and often violent. You need someone in your corner standing up for you and fighting to protect you, your job and your family’s income. CLEAT is the best, largest, and most respected organization fighting for Texas’ finest. Now, over 45 years later, CLEAT is the largest police labor organization in the state and stronger than ever. With more than 100 local affiliates, and with more than 40 world-class professional staff located in every area of Texas, CLEAT is continually growing, continually seeking to live up to our motto: Strength, Justice and Unity. 
<h3>Company Description</h3>
The Combined Law Enforcement Associations of Texas, or CLEAT, was born during the mid-1970’s by innovative police officers seeking to enhance the law enforcement profession.\r\n\r\nCLEAT’s rich history begins with rank and file officers not being represented. The organization began by separating itself from a do-nothing, pro-management organization that refused to represent its members.\r\n\r\nMany of the founders were returning veterans of the Vietnam War era and were unhappy with the way their statewide police association’s (TMPA) refusal to hire attorneys or represent members when they were disciplined, demoted or terminated. Like our nation’s founders, these officers met with the leaders of TMPA and attempted to change the organization from within.\r\n\r\nThe officers aired their grievances about how things were being handled and after seeing zero change, year after year, these officers began asking one another why they couldn’t just form their own union that would actually represent street cops and get things done in a state that no longer fit the mold of the largely rural, good ole boy, pro-management state-wide association that had failed them badly.\r\n\r\nAfter a dramatic walkout of the annual convention, the officers banded together, created a real union for working officers and never looked back. At every milestone, the naysayers predicted CLEAT and its leaders would fail. But CLEAT leaders and members forged ahead, lending of themselves, their lives and futures in order to build an organization that worked for all officers.\r\n\r\nAs a law enforcement professional your job is difficult, dangerous and often violent. You need someone in your corner standing up for you and fighting to protect you, your job and your family’s income. CLEAT is the best, largest, and most respected organization fighting for Texas’ finest.\r\n\r\nNow, over 45 years later, CLEAT is the largest police labor organization in the state and stronger than ever. With more than 100 local affiliates, and with more than 40 world-class professional staff located in every area of Texas, CLEAT is continually growing, continually seeking to live up to our motto: Strength, Justice and Unity.

Staff Attorney for Police Union

<h3>Job Description</h3>
Job DescriptionSalary: $103,000 - $114,450 annually 
WHITMAN COLLEGE
Located in the historic community of Walla Walla, Whitmans vibrant and beautiful tree-lined campus is home to an intellectually diverse, dynamic, welcoming and supportive community of some 500 staff and faculty serving approximately 1,500 students from the local region and across the globe. With exceptional students, accomplished faculty and staff, and a fiercely loyal and growing number of engaged alumni, Whitman College continues to build on its national reputation for academic excellence as one of the top liberal arts colleges in the country.
Whitman College is cultivating a community built on inclusion and belonging. We recognize the value of those who can offer historically underrepresented perspectives and encourage applications from those whose background, knowledge, and insights from lived experience can add to the colleges working and learning environment. Whitman College is an Equal Employment Opportunity employer (EEO).
 
POSITION PURPOSE
Under the supervision of the Vice President for Inclusive Excellence (VPIE), the Director of Equity and Compliance/Title IX Coordinator is directly responsible for coordinating compliance with federal and state discrimination, harassment, and retaliation laws and related College policies. This includes those related to sexual and gender-based misconduct and identity-based harassment and discrimination (i.e., Title IX and Title VI). The Director works collaboratively with Human Resources (HR), the Office of the Provost, Campus Security, Student Affairs and other campus partners to develop and maintain policies, reporting protocols and prevention strategies. This role conducts initial assessments of reported concerns, ensures appropriate documentation of complaint resolutions, and reports findings to designated areas for further action when necessary. This position will temporarily report to the Associate Vice President (AVP) for HR during the search for a new VPIE, after which it will report directly to the VPIE.
 
PRINCIPAL ACCOUNTABILITIES
Response &amp; Investigation of Title IX, Title VI &amp; Other Complaints of Identity-Based Harassment &amp; Discrimination (60%)
<ul>
<li>Receive reports/complaints of harassment, discrimination, sexual misconduct and retaliation from students, faculty and staff.</li>
<li>Conduct initial assessments, meet with complainants to provide information on campus and community resources, communicate supportive measures and explain options for confidential reporting and resolution.</li>
<li>Ensure prompt, effective, and equitable investigations and timely resolution of complaints of sexual misconduct, retaliation, and other forms of identity-based harassment and discrimination.</li>
<li>Organize and maintain accurate and thorough case files, investigation records, statistical data on inquiries and complaints, and develop reports on complaints, investigations, and resolutions as required by law.</li>
<li>Assist in the construction of informal resolutions for incidents that do not meet the threshold for formal investigation.</li>
<li>Responsible for the notification of parties, oversight of investigation and investigative reports to ensure investigations are thorough, reliable and impartial, and monitoring compliance with necessary laws, policies and guidelines. When necessary, will coordinate, appoint, and oversee the work of external investigators and/or deputy coordinators.</li>
<li>Organize and support a system of volunteer Deputy Title IX Coordinators, as well as provide training to staff members responsible for any part of the complaint process (i.e., investigators, hearing panelists, advisors, etc.).</li>
<li>Develop, implement, update and serve as principal coordinator of policies, procedures and programs related to compliance with Titles VI and VII of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, the Violence Against Women Act (VAWA) and other applicable legislation.</li>
<li>Maintain fluency with Title IX and Title VI regulations and consult with legal counsel as appropriate.</li>
<li>Maintain a high level of confidentiality with the utmost discretion and sensitivity.</li>
</ul>
Education &amp; Training (15%)
<ul>
<li>Collaborate with the Division of Inclusive Excellence, HR and Student Affairs to develop, offer and coordinate training and awareness efforts related to all forms of discrimination, harassment and retaliation with an emphasis on prevention education.</li>
<li>Maintain documentation of training and educational programs related to compliance with Title IX and VAWA; provide certifications as required to state and government reporting bodies.</li>
</ul>
Grievances &amp; ADA Appeals (15%)
<ul>
<li>Serve as an investigative administrator for the Colleges Grievance process.</li>
<li>Hear appeals of decisions regarding ADA accommodations (i.e., student appeals decided by the Director of Disability Support Services; employee appeals decided by the AVP for HR).</li>
</ul>
Evolving Responsibilities (10%)
<ul>
<li>Assist with Clery reporting and compliance.</li>
<li>Provide strategic direction for, and ongoing assessment and evaluation of, all efforts to eliminate and prevent harassment, discrimination, retaliation, and sexual misconduct at Whitman College.</li>
<li>Serve as a critical campus resource and College representative, internally and externally, in support of equity.</li>
<li>Lead and serve on College committees as needed.</li>
</ul>
 
REQUIRED KNOWLEDGE, SKILLS &amp; ABILITIES
Must be able to explain and/or demonstrate possession of the knowledge, skills, and abilities to safely perform the essential functions of the job, with or without reasonable accommodation. Specifically,
<ul>
<li>Ability to interpret federal and state equal opportunity and nondiscrimination laws and regulations, including Title IX, Title VI, sexual harassment and other applicable laws and regulations.</li>
<li>Working knowledge of Title VI and VII of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, the Violence Against Women Act Reauthorization of 2012 (VAWA), Campus SaVE Act and related laws.</li>
<li>Understanding of bias and a clear commitment to diversity, equity, inclusion and the ability to integrate this value into all aspects of the position.</li>
<li>Ability to actively and positively contribute to the Colleges core values of diversity, equity, inclusion, antiracism and access.</li>
<li>Ability to collaborate, identify opportunities and act to build effective relationships across the College to achieve institutional compliance goals.</li>
<li>Strong organization, planning, analytical and problem resolution abilities.</li>
<li>Excellent verbal and written communication, interpersonal, administrative, organizational, planning, and project management skills.</li>
<li>Ability to treat all parties engaged in the complaint process with sensitivity and neutrality.</li>
<li>Ability to manage sensitive situations with professionalism and compassion, while maintaining credibility.</li>
<li>Ability to conduct individual and group facilitations to foster effective communication.</li>
<li>Ability to multitask and organize, prioritize, and follow multiple projects and tasks through to completion with an attention to detail.</li>
<li>Ability to work independently while contributing to a team environment.</li>
<li>Ability to maintain confidentiality and professional relationships in dealing with sensitive, complex civil rights, legal, and human resources issues.</li>
</ul>
 
MINIMUM QUALIFICATIONS
<ul>
<li>Masters degree in relevant discipline (Public Administration, Higher Education, Human Services, Counseling Psychology, etc.) from an accredited institution.</li>
<li>2+ years of experience with Title IX work and requisite knowledge for overseeing Title VI investigations AND experience and training leading investigations of identity-based discrimination or harassment.</li>
<li>OR a combination of relevant education, training, and experience. </li>
</ul>
Whitman College values diverse pathways to acquiring skills and knowledge and encourages applicants to demonstrate how their background aligns with the role.
 
PREFERRED QUALIFICATIONS
<ul>
<li>Law degree in relevant discipline (Public Administration, Higher Education, Human Services, Counseling Psychology, etc.) from an accredited institution.</li>
<li>Training in trauma-informed, mediation, conflict resolution, or restorative justice practices.</li>
<li>Knowledge of database management systems such as Maxient, Symplicity, Guardian, or other appropriate software.</li>
</ul>
Please note that while the description details both required and preferred qualifications, we want applicants to be aware that they do not need to have all of the preferred qualifications to be considered for this position. If you meet the minimum qualifications and have passion for the work, you are encouraged to apply. 
 
BENEFITS
Whitman College offers a competitive benefits program that is designed to attract qualified candidates and retain talented employees. Full-time employees enjoy the following benefits:
 
Medical/Dental/VisionInsurances.
Basiclife,accidental death and dismembermentandlong term disabilityinsurances with the capability to elect additional voluntary coverage.
403(b) Defined Contribution Retirement Planwith a 10% matching contribution aftereligibility requirementsare met.
Paid Time Off:20 accrued vacation days,12 accrued sick days,13 paid holidays.
Tuition Remission Dependent Children
Employeetuition waiver for two Whitman courses per semester.
Employee Assistance Program
Relocation assistance for eligible employees.
Learn more about benefits eligibilityhere. 
 
DISABILITY ACCOMMODATION FOR JOB CANDIDATES
Contact Human Resources regarding requests for disability accommodation in the employment application process.
 
APPLICATION REVIEW
Application review will begin on immediately and continue until the position is filled. 
 
START DATE
ASAP

Director of Equity and Compliance/Title IX Coordinator

<h3>Job Description</h3>
Job Description
Overview
Are you looking for a career you can feel good about? We hire only those that strive to do their best. By joining our family, you'll receive the honor and recognition that comes with working for the industry's global leader in evidenced based rehabilitation.
Who We Are:
GEO provides complementary, turnkey solutions for numerous government partners worldwide across a spectrum of diversified correctional and community reentry services. From the development of state-of-the-art facilities and the provision of management services and evidence-based rehabilitation to the post-release reintegration and supervision of individuals in the community, GEO offers fully diversified, cost-effective services that deliver enhanced quality and improved outcomes.
Why Work for GEO:
<ul>
<li>We believe that work is more than a place you go to every day. It is about being inspired and motivated to achieve extraordinary things.</li>
<li>Employee benefits play an important role in making The GEO Group a great place to work. At GEO, we believe in the three pillars of employee wellbeing: physical, emotional, and financial. With comprehensive benefits and competitive wages, we trust that you will find all the resources you need here to be successful.</li>
</ul>
 
Responsibilities
Summary
This position focuses on serving the needs, concerns and objectives of both managers and our employees through building effective partnerships and by creating trust and mutual respect. It leads the administration and implementation of Human Resources (HR) policies, programs and practices throughout the facility and acts as the liaison between the facility management and Regional/Corporate HR.
Primary Duties and Responsibilities
<ul>
<li>Serves as an advisor to the Facility Administrator and facility management on Human Resources issues.</li>
<li>Supports local recruiting and outreach efforts in coordination with the centralized recruiting team to meet or exceed monthly and annual recruiting targets in the most efficient and effective manner possible. Ensures a positive candidate and hiring manager experience. Prepares and maintains personnel records and ensures compliance to procedures for controlling personnel transactions and reporting personnel data. Administers and tracks employee developmental training.</li>
<li>Assists, coaches and provides guidance for progressive discipline, standards of employee conduct and employee terminations.</li>
<li>Supports reporting serious staff misconduct to the Office of Professional Responsibility (OPR).</li>
<li>Engages employees and acts as a conduit to provide facility management, Regional HR and Corporate HR insight into employee concerns.</li>
<li>Responsible for employee onboarding to include data entry into the HR Information system and new employee orientation. Ensures that data entered is accurate and employees have a thorough understanding of Company policies and procedures, to include the information included in the employee handbook.</li>
<li>Responsible for maintaining records of insurance coverage, retirement plans, and personnel transactions such as hires, promotions, transfers, performance reviews, terminations, and other related personnel and payroll issues.</li>
<li>Serves as EEO specialist and maintains affirmative action plan.</li>
<li>Serves as subject matter expert for leaves of absences, FMLA and ADA issues.</li>
<li>Ensures compliance with Company policies and procedures and develops a thorough understanding of Corporate HR policies and procedures.</li>
<li>Reviews facility personnel procedures to ensure that they are applicable, effective, and comply with contract requirements, local, state and federal law, and Company policies, procedures.</li>
<li>Resolves employee personnel inquiries and submits necessary inputs, changes, additions and deletions into the HR Information System for correction. Refers unusual or unresolved problems to Regional HR for further action.</li>
<li>May manage an assigned human resources staff and perform the duties typically associated with a management level position including hiring, training, and employee development.</li>
<li>Coordinates grievance and disciplinary hearings and activities.</li>
<li>Coordinates benefit programs, annual enrollment, and employee wellness program at facility.</li>
<li>Monitors unemployment claims, assists with appeals and may attend hearings as the Human Resources representative.</li>
<li>Partners with facility management to ensure the performance appraisal program is compliant and effective.</li>
<li>Provides guidance on compensation, bonuses and other recognition programs.</li>
<li>Monitors and coordinates workers’ compensation claims and may compile information to file workers’ compensation claims for employees and for the insurance carrier.</li>
<li>Provides necessary referral support for the Employee Assistance Program (EAP).</li>
<li>Performs other duties as assigned.</li>
</ul>
 
Qualifications
Minimum Requirements
<ul>
<li>High school diploma with a minimum of seven (7) years of progressive professional experience in Human Resources or a Bachelor’s degree from an accredited college or university in Human Resources or related field with five (5) years of experience working in a Human Resources position.</li>
<li>Three (3) years supervisory experience preferred.</li>
<li>Must exhibit leadership qualities to gain the respect of all employees and be able to display confidence when interacting with people at all levels of management.</li>
<li>Must have the ability and desire to work in a cooperative manner and to make management decisions.</li>
<li>Experience working with an HR Information System required.</li>
<li>Must be able to maintain confidentiality at all times due to the handling of sensitive and confidential information.</li>
<li>Must have the ability to communicate effectively, both verbally and in writing.</li>
<li>Must have proficiency in Microsoft Office suite (Windows, MS Word, Excel, and PowerPoint) and other computer programs and software normally used by HR.</li>
</ul>
GEO Secured Services

HUMAN RESOURCES MANAGER

<h3>Job Description</h3>
Job Description
Overview
Seeking a Sales Account Representative/Executive for our Signature Advantage Plan who will work with senior care partners to assist in enrolling new residents and members. You will actively market our plan to new senior care partners within a plan service area.
We value candidates with direct sales and account management experience, a KY or TN State Insurance Licence (or willingness to quickly get one), and experience working with our elder community. Regional Travel is required.
Our salary of $64,000- 66,000/year includes eligability for an incentive bonus paid monthly!
 
Responsibilities
<ul>
<li>Working with senior care partners to assist with enrolling new resident members and discussing plan benefits with senior care partners, potential plan members and their families.</li>
<li>Responsible for educating members on the plan and providing high quality customer service, providing professional, accurate and timely response to all inquiries regarding eligibility, plan coverage, coordination of benefits and claim payment solutions.</li>
<li>Assisting with resolution to Member and Provider issues. Refer all unresolved issues to the next level including grievance and appeals.</li>
<li>Actively market plan to new senior care partners within plan Service Area.</li>
<li>Assist with identifying key providers in market area that would enhance plan’s network.</li>
<li>Meet the physical and sensory requirements stated below and be able to work in the described environment.</li>
<li>Responsible for year-round enrollment of eligible individuals into Signature Advantage’s Institutional Special Needs Plan(s).</li>
<li>Manage market territory with plan service area.</li>
<li>Meeting New and existing members to collect information on early interventions for service or health needs and communicate this back to the Care Team.</li>
<li>Deliver approved sales and marketing presentations in accordance with applicable Centers for Medicare &amp; Medicaid Services (CMS) and State guidelines and standards.</li>
<li>Conduct individual meetings, small group presentations and attend scheduled facility rollout meetings as needed.</li>
<li>Must communicate effectively with Medicare beneficiaries, their families, caretakers, nursing facility management and staff.</li>
<li>Must consistently achieve established sales goals and report all sales and field marketing results daily.</li>
<li>Responsible for tracking and maintaining accurate records in compliance with HIPAA / HITECH laws and Signature Advantage policies and procedures.</li>
<li>Other special projects and duties, as assigned.</li>
</ul>
 
Qualifications
<ul>
<li>Two-year associate/technical degree, bachelor’s degree or experience with direct sales and account management preferred.</li>
<li>Tennessee/Kentucky State Health Insurance License required.</li>
<li>Experience working with the senior population preferred.</li>
<li>Ability to organize and manage multiple priorities is necessary.</li>
<li>Must be self-directed, highly motivated and possess excellent interpersonal communication skills.</li>
<li>Ability to prospect, set-up, present, close and utilize time for maximum results.</li>
<li>Problem analysis and problem resolution.</li>
<li>Ability to work independently with minimal direct supervision.</li>
<li>Must have reliable transportation and be able to pass a background check.</li>
<li>Regional travel is expected.</li>
<li>Effective verbal and written English communication skills.</li>
<li>Demonstrated intermediate to advanced skills in Microsoft Word, Excel, Power Point and Outlook, Internet and Intranet navigation.</li>
<li>Highest level of professionalism with the ability to maintain confidentiality.</li>
<li>Ability to communicate at all levels of organization and work well within a team environment in support of company objectives.</li>
<li>Customer service oriented with the ability to work well under pressure.</li>
<li>Strong attention to detail and accuracy, excellent organizational skills with ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity.</li>
<li>Strong analytical and problem-solving skills.</li>
<li>Ability to work with minimal supervision, take initiative and make independent decisions.</li>
<li>Ability to deal with new tasks without the benefit of written procedures.</li>
<li>Approachable, flexible and adaptable to change.</li>
<li>Function independently, and have flexibility, personal integrity, and the ability to work effectively with stakeholders and vendors.</li>
</ul>

Medicare Sales Account Representative

<h3>Job Description</h3>
Job DescriptionSummary Description:
The Appeals &amp; Grievances Nurse requires the abilities and knowledge of a California-licensed Registered Nurse (RN). Specifically, the Appeals &amp; Grievances Nurse reports directly to Western Health Advantage’s (WHA’s) Utilization Operations Director and reviews appeal and grievance cases requiring clinical evaluation. This position works closely with WHA’s Appeals &amp; Grievances Supervisor and staff, Medical Director, Chief Medical Officer, and Clinical Pharmacists to ensure that Utilization Management (UM) review functions are carried out effectively at the corporate health plan level. This position works consistently work with the Appeals &amp; Grievances Department to provide clinical evaluation, problem solving, and direction on appeal and &nbsp;&nbsp;grievance cases, to include completion of case summaries for presentation to the Appeal Review Meeting. Additionally, this position assists the Senior Appeals &amp; Grievances Nurse with review of written response to requests that come from the CA Department of Managed Health Care (DMHC) and with expedited requests, to include appeals regarding discharge or transfer of a Plan member.
Representative Duties:
• Review all appeal/grievance requests involving medical necessity or that require clinical evaluation, and coordinate with all entities involved within the provision of contracts and delegation agreement between the Contracted Medical Groups and Hospital Systems.
• Perform research, evaluation and case preparation of complex appeal &amp; grievance requests involving new technology and experimental treatments.
• Evaluate appeal cases to determine clinical urgency and provide direction to Appeals &amp; Grievances staff.
• Work with our Medical Groups regarding post, concurrent, and retrospective review of member appeals when involving admissions/discharges through hospitals, skilled nursing facilities, and acute rehabilitation units, to include referrals to care management for assistance, and coordinates services with Medical Group review staff, as needed (i.e., works with hospital discharge planners and Medical Group nurses to ensure smooth transfers, appropriate discharges, in- network follow-up care/services, etc.).
• Maintain effective and routine interaction with representatives from contracted IPAs/Medical Groups to ensure timely access to care, assist with benefit interpretation, treatment for Plan members, coordination of care, and that all UM letters align with WHA’s standards, upon appeal review.
• Interface and collaborate with departmental team members, as well as other functional area leaders, on special projects and/or towards the accomplishment of company-wide business goals, objectives and project deliverables.
• Provide direction and coordination to the Appeals &amp; Grievances Department regarding Commercial and Medicare appeals and grievances cases.
• Draft resolution letters for Medical Directors with regarding to appeal cases that are upheld for medical necessity. This includes utilization of member plan guidelines, copayment summaries, or the Evidence of Coverage.
• Assist Utilization Operations Director in the development and provision of educational materials and information for WHA staff and delegated IPA/Groups related to Plan benefits and UM/CM, as well as A&amp;G, processes.
• Assist in maintaining a current quick reference guide for review staff by updating WHA’s Prior Authorization and DME Benefit Matrix.
• Participate with the Appeals &amp; Grievances team in the implementation, review, and analysis of studies and audits, with special attention to technical assistance guide and technical specifications for performance measurement activities.
• Participate in Appeals &amp; Grievances readiness for regulatory agency audits, accreditation surveys, responds to request for proposals (RFP), with preparation of reports, documents, and binders.
• Participate in conference calls with the CA DMHC attorneys and their senior council regarding appeal/grievance cases, to include submission of information for an Independent Medical Review.
• Provide clinical support for evaluation, problem solving and direction to Clinical Resources Nurses and Appeals &amp; Grievances staff on processing, research, and resolution of appeal and grievance cases.
• Provide clinical support for sales, marketing and wellness department activities as needed – including developing or reviewing written materials, presentations and or activities.
• Coordinate with Appeals &amp; Grievances and Quality Management staff to ensure screening of cases identified as possible Potential Quality Issues.
• Assist with escalation of evaluation review for utilization of non-network emergency/urgent hospital admissions and transfers and provide support to the CRN to facilitate the provision of appropriate services through effective collaboration with all stakeholders. It is important to note that routine utilization and case management functions are delegated by WHA to its contracted IPAs, Medical Groups and other carve-out entities.
• Thoroughly research, review, and prepare cases for Medical Director review, and ensure timely and appropriate follow-up by creating and sending authorization/approval or denial letters, etc. (e.g., OOA second opinions, organ transplants, cancer clinical trials, new technology/experimental determinations, etc.).
• Assist Member Service Representatives and IPA/Medical Group Utilization Management staff with interpretation of benefits, eligibility requirements and regulatory compliance issues regarding UM &amp; A&amp;G processes for Commercial and Medicare members.
• Initiate and follow up on members identified for referral for Case Management, Disease Management and/or Behavioral Health services.
• Provide care coordination, education and support for members undergoing transgender surgery services.
• Assist with DMHC &amp; CMS regulatory and NCQA accreditation audits.
• Perform other duties and special projects as assigned.
Qualifications:
<ul>
<li>
Bachelor’s Degree in Nursing.
</li>
<li>
3 years’ experience in utilization/case management, discharge planning and/or appeals &amp; grievances in a managed care&nbsp;environment, with increased responsibilities.
</li>
<li>
Valid Registered Nurse (RN) License is required prior to employment and must be maintained for the duration of employment.
</li>
<li>
Utilization Management, Quality Management, or CCM certification a plus but not required.
</li>
<li>
Experience with California Code of Regulation with the CA Department of Managed Healthcare, regulations with the Centers for Medicare &amp; Medicaid Services (CMS), as well as the technical specification requirements under the National Committee for Quality Assurance (NCQA) accreditation.
</li>
<li>
Intermediate computer skills, including electronic mail, routine database activity, word processing, spreadsheet, graphics, etc. Specifically, the ability to create formulas and graphs in Excel and import them into Word documents.
</li>
</ul>
Must be able to speak, read, write, and understand the primary language(s) used in the workplace.
Salary:
$85,000.00 – $115,000.00 Annually
Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law.
Western Health Advantage values and supports the unique talents and strengths that each employee brings to our organization. Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you — and excellent customer service for our members.
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Appeals & Grievances Nurse

<h3>Job Description</h3>
Job Description
Hybrid-Sunrise, Florida
Position Summary:
As a part of the Quality Department, this position investigates and finds resolution of complaints, grievances and member appeals based upon specific regulatory requirements. In addition, the assembly and preparation of State Fair Hearing/IRO packets as well as coordination and participation in State Fair Hearings. 
Essential Duties and Responsibilities:
<ol>
<li>Receives, researches, resolves, tracks trends, and reports all complaints, grievances, and appeals for all lines of business.</li>
<li>Maintains complaint, grievance, and appeal logs for all lines of business.</li>
<li>Responsible for case development and resolution of all complaints, grievances and appeals. The end-to-end process requires the coordinator to:
<ul>
<li>Research issues and obtain additional documentation as applicable</li>
<li>Reference and understand CCP’s internal policies and procedures to frame decisions. </li>
<li>Interpret regulations </li>
<li>Resolve cases and make critical decisions </li>
<li>Manage all duties within regulatory timeframes </li>
<li>Finalize and send acknowledgment and resolution correspondence </li>
</ul>
</li>
</ol>
<ol>
<li>Oversees the resolution of member complaints, grievances, and appeals related to quality of care and service, medical necessity, plan benefits and payments to ensure compliance with state and federal regulations and NCQA standards. </li>
<li>Coordinates monthly and ad hoc grievance and appeals committee meetings. </li>
<li>Communicate grievance and appeals decision to the participant within regulatory guidelines for timeliness, adhering to the strictest of timeframes for urgent and non-urgent requests, as imposed by the various federal and state laws.</li>
<li>Ensures thorough, accurate and timely processing of appeals using the internal appeals, independent external review or Medicaid Fair Hearing process. </li>
<li>Analyze complaint, grievance and appeal data, develop trend reports and work with various committees to identify opportunities for improvement to increase member satisfaction. </li>
<li>Monitor delegated partners in care complaint, grievance and appeal activity to ensure compliance. </li>
<li>Partner with other business areas to identify issues and develop appropriate action plans to address deficiencies. </li>
<li>Prepare comprehensive report for submission to the Agency for Healthcare Administration monthly and the Florida Healthy Kids Corporation quarterly. </li>
<li>Report data and make recommendations to the appropriate internal committees and workgroups such as the Quality Improvement Committee. </li>
<li>Maintain thorough knowledge of contract requirements, accreditation standards, and new and existing laws and regulations. </li>
<li>Develop, update and maintain grievance and appeal policies and procedures to support new lines of business and reflect changes in contract language, accreditation standards and updates in laws or regulations. </li>
<li>Design and implement departmental trainings to ensure quicker resolution of member issues and a better understanding of member appeal rights. </li>
<li>Work with internal stakeholders in federal, state, and/or internal audits of grievance and appeals processes as well as data validation activities, as needed. Takes the lead in presenting appeals and all grievance documentation during a mock or actual audit.</li>
<li>Perform other duties as necessary. </li>
</ol>
This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.
Qualifications: 
<ul>
<li>Must have high school diploma or General Education degree (GED); Associates degree preferred; and two to four years related experience and/or training; or equivalent combination of education and experience.</li>
<li>1 to 2 years of health care experience. </li>
<li>Conversant with HIPPA regulations, Medicaid and CHIP. </li>
<li>Working knowledge of Microsoft software products such as Word and Excel.</li>
</ul>
Skills and Abilities:
<ul>
<li>Problem solving— Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.</li>
<li>Verbal communication—speaks clearly and persuasively in positive or negative situations; Listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Participates in meetings.</li>
<li>Written communications—writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.</li>
<li>Demonstrates flexibility with a willingness to learn and adapt to changes in regulations and task-related priorities </li>
</ul>
Work Schedule:
 Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs
 
Physical Demands: 
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.
Work Environment: 
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.
We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating and preserving a culture of diversity, equity and inclusion.

Grievances & Appeals Coordinator

<h3>Job Description</h3>
Job Description
CLEAT CRIMINAL ATTORNEY JOB DESCRIPTION/REQUIREMENTS
Location: Houston, TX (in-office with hybrid flexibility)
Position Type: Full-time
Compensation: 135k + benefits (health, vision, dental, 401(k))
Key Responsibilities:
We are seeking a skilled and dedicated Criminal Defense Attorney licensed to practice in Texas to join our dynamic legal team. The ideal candidate will have a strong background in criminal law, courtroom advocacy, and client representation. This role involves managing a diverse caseload, negotiating with prosecutors, and defending clients in misdemeanor and felony matters across state and federal courts.
Other Key Responsibilities:
- Represent clients in criminal proceedings, including arraignments, hearings, trials, and appeals
- Conduct legal research and draft motions, briefs, and other court filings
- Develop case strategies and advise clients on legal options and potential outcomes
- Negotiate plea deals and settlements with prosecutors
- Appear in court regularly and advocate zealously on behalf of clients
- Maintain accurate case files and documentation in compliance with firm protocols
- Collaborate with investigators, experts, and support staff to build strong defenses
- Stay current with changes in Texas criminal statutes, case law, and procedural rules
- To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Qualifications:
- Juris Doctor (JD) from an accredited law school
- Active license to practice law in Texas and in good standing with the State Bar
- Minimum 7 years of experience in criminal defense (misdemeanor and felony cases)
- Strong litigation and negotiation skills
- Excellent written and verbal communication abilities
- Ability to manage multiple cases and deadlines effectively
- Commitment to ethical practice and client confidentiality
Preferred Experience
- Prior work in a public defender’s office or criminal law firm
- Familiarity with Texas Penal Code and Code of Criminal Procedure
- Bilingual (Spanish/English) is a plus
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following: Assists Members in administrative investigations and hearings, disciplinary and grievance matters, Criminal, Civil and other labor/employment cases.
Gathers evidence in administrative discipline, civil, criminal, and other cases to formulate defense or to initiate legal action. Conducts research, interviews clients, and witnesses and handles other details in preparation for trial or hearing.
Prepares APPEALS, legal briefs, develops strategy, arguments and testimony in preparation for presentation of case. Files legal documents with court clerk.
Represents client in court, and before quasi-judicial or administrative agencies of government. Interprets laws, rulings, and regulations for individual members and local associations. Drafts and/or reviews legal documents.
Assists Members in the preparation, review and signing of Will documents.
Advises local associations concerning transactions of business involving internal affairs, directors, officers and corporate relations with general public.
Respond to Critical Incidents by appropriate CIRT protocols. Serves on rotating basis for critical incident "on call" duties.
Travel to other regions in Texas to represent members or other interests of CLEAT, as needed or as directed by supervisory personnel.
SUPERVISORY RESPONSIBILIITIES
This job has no supervisory responsibilities.
EDUCATION and/or EXPERIENCE
Juris doctorate from an accredited law school. 7+ years’ experience preferred for this position.
LANGUAGE SKILLS
Ability to read, analyze, and interpret the most complex documents. Ability to respond effectively to the most sensitive inquiries or complaints, in person, or hearings. Ability to make persuasive arguments and articulate on controversial or complex topics to top management, public groups, governmental bodies, arbitrators, and/or courts of law.
REASONING ABILITY
The ability to apply principles of logical and deductive reasoning skills necessary for creative thinking and strategic problem solving.
CERTIFICATES, LICENSES, REGISTRATIONS
Juris doctorate from an accredited law school. Current bar license from State Bar of Texas. A valid Texas driver’s license, to operate a motor vehicle currently registered and inspected.
PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this Job, the employee is regularly required to speak and listen in order to effectively communicate. The employee is frequently required to sit for hours at a time. The employee is occasionally required to stand; walk and reach with hands and arms. The employee must regularly lift and /or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision and ability to adjust focus.
Operate a motor vehicle in many different weather conditions and, environments as well as drive day or night.
WORK ENVIRONMENT The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Some travel required; some overnight stay required on CLEAT business to include cases that are not local, arbitrations, court cases and continuing legal education.
Office environment is 1-3 attorneys, and possibly others. The noise level in the work environment is usually moderate.
COMPUTER SKILLS
To perform this job successfully, an individual should have working knowledge of Zoom, TEAMS, Outlook, Word, and TxDocs/Prodoc, and Westlaw and/or LexisNexis as well as other word processing software. Proficient in using the CLEAT on-line membership database to confirm membership benefits.
Company DescriptionThe Combined Law Enforcement Associations of Texas, or CLEAT, was born during the mid-1970’s by innovative police officers seeking to enhance the law enforcement profession. CLEAT’s rich history begins with rank and file officers not being represented. The organization began by separating itself from a do-nothing, pro-management organization that refused to represent its members. Many of the founders were returning veterans of the Vietnam War era and were unhappy with the way their statewide police association’s (TMPA) refusal to hire attorneys or represent members when they were disciplined, demoted or terminated. Like our nation’s founders, these officers met with the leaders of TMPA and attempted to change the organization from within. The officers aired their grievances about how things were being handled and after seeing zero change, year after year, these officers began asking one another why they couldn’t just form their own union that would actually represent street cops and get things done in a state that no longer fit the mold of the largely rural, good ole boy, pro-management state-wide association that had failed them badly. After a dramatic walkout of the annual convention, the officers banded together, created a real union for working officers and never looked back. At every milestone, the naysayers predicted CLEAT and its leaders would fail. But CLEAT leaders and members forged ahead, lending of themselves, their lives and futures in order to build an organization that worked for all officers. As a law enforcement professional your job is difficult, dangerous and often violent. You need someone in your corner standing up for you and fighting to protect you, your job and your family’s income. CLEAT is the best, largest, and most respected organization fighting for Texas’ finest. Now, over 45 years later, CLEAT is the largest police labor organization in the state and stronger than ever. With more than 100 local affiliates, and with more than 40 world-class professional staff located in every area of Texas, CLEAT is continually growing, continually seeking to live up to our motto: Strength, Justice and Unity. 
<h3>Company Description</h3>
The Combined Law Enforcement Associations of Texas, or CLEAT, was born during the mid-1970’s by innovative police officers seeking to enhance the law enforcement profession.\r\n\r\nCLEAT’s rich history begins with rank and file officers not being represented. The organization began by separating itself from a do-nothing, pro-management organization that refused to represent its members.\r\n\r\nMany of the founders were returning veterans of the Vietnam War era and were unhappy with the way their statewide police association’s (TMPA) refusal to hire attorneys or represent members when they were disciplined, demoted or terminated. Like our nation’s founders, these officers met with the leaders of TMPA and attempted to change the organization from within.\r\n\r\nThe officers aired their grievances about how things were being handled and after seeing zero change, year after year, these officers began asking one another why they couldn’t just form their own union that would actually represent street cops and get things done in a state that no longer fit the mold of the largely rural, good ole boy, pro-management state-wide association that had failed them badly.\r\n\r\nAfter a dramatic walkout of the annual convention, the officers banded together, created a real union for working officers and never looked back. At every milestone, the naysayers predicted CLEAT and its leaders would fail. But CLEAT leaders and members forged ahead, lending of themselves, their lives and futures in order to build an organization that worked for all officers.\r\n\r\nAs a law enforcement professional your job is difficult, dangerous and often violent. You need someone in your corner standing up for you and fighting to protect you, your job and your family’s income. CLEAT is the best, largest, and most respected organization fighting for Texas’ finest.\r\n\r\nNow, over 45 years later, CLEAT is the largest police labor organization in the state and stronger than ever. With more than 100 local affiliates, and with more than 40 world-class professional staff located in every area of Texas, CLEAT is continually growing, continually seeking to live up to our motto: Strength, Justice and Unity.

CRIMINAL ATTORNEY - CLEAT HOUSTON OFFICE

<h3>Job Description</h3>
Job DescriptionDescription:
Verda Health Plan of Texas has a contract with the Center of Medicaid and Medicare Services (CMS) and a state license with the Texas Department of Insurance for a Medicare Advantage Prescription Drug (MAPD) plan. We are committed to the idea that healthcare should be easily and equitably accessed by all. Our mission is to ensure that underserved communities have access to health and wellness services, and receive the support needed to live a healthy life that is free of worry and full of joy. We are looking for a Grievance &amp; Appeal Representative to join our growing company with many internal opportunities.
 
Are you ready to join a company that is changing the face of health care across the nation? Verda Healthcare, Inc is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity. Align your career goals with Verda Healthcare, Inc and we will support you all the way.
 
Position Overview
The Grievance &amp; Appeal Representative responds to all types of written/verbal grievances, complaints, appeals and disputes submitted by members and providers: review, analyze, research, respond and resolve all inquiries, in accordance with guidelines established by CMS and other regulatory agencies, where applicable, as well as internal policies. Will work with Clinical department regarding appeals related to Clinical policy. Work as an effective interface between internal and external customers. Maintain good member and provider relations relationship. 
 
****This position is part of Call Center. This position reports to the Manager of Enrollment. 
 
Job Responsibilities
· Review and evaluate appeal and grievance request to identify and classify member and provider appeals, hand-off to appropriate department for provider and clinical appeals; process member and provider complaints as appropriate to meet the CMS, State and Accreditation requirements. 
· Determine eligibility, benefits, and prior activity related to claims, payment or service in question.
· Review research performed by operational areas to ensure the appropriate resolution to the appeal/grievance has been achieved, review contracts, member materials, medical payment policies, and provider education documents in researching and deciding the outcome of appeals.
· Accountable for appropriate review and determination in compliance with state and federal regulations.
· Conduct thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities.
· Perform comprehensive research related to the facts and circumstances of a member complaint, to include appropriate classification as a grievance, appeal, or both, in accordance wit regulatory requirements.
· Research appeal files for completeness and accuracy and investigate deficiencies. Consult with internal areas as required (such as the Legal Department) to clarify legal ramifications around complex appeals.
· Provide written acknowledgement of member and provider correspondence, prepare written responses to all member and provider correspondence that appropriately address each complaint’s issues and are structurally accurate. 
· Follow-up with departments responsible to ensure compliance.
· Responsible for making verbal contact with the member or authorized representative during the research process to further clarify, as needed, for the member’s complaint. 
· Ensure documentation requirements are met create and document service requests to track and resolve issues; document final resolutions along with all required data to facilitate accurate reporting, tracking and trending. 
· Provide all follow up documentation of outcome to practitioners, providers, and members. 
· Responsible for the timely, complete, accurate documentation of the appeal and/or grievance both electronically, and hard copy, and for timely and accurate written documentation to the member and/or provider advising of the resolution of the appeal and/or grievance. 
· Responsible for ensuring appeals case files are accurately prepared and submitted to the IRE within 24 hours of the decision to uphold the initial denial for expediated appeals, and not later than 30 calendar days after the receipt of a standard pre-service appeal and 60 days after the receipt of a claim appeal. 
· Enter and maintain critical data and records in support of Verda Health Plan business requirements, regulatory obligations timeframes, monitor daily and weekly pending reports and personal worklists, ensuring internal and regulatory timeframes are met. 
· Enter and maintain critical data and records in support of business requirements, regulatory timeframes, and NCQA standards, into the appropriate systems. 
· Track and trend outcomes and analyze data to provide reporting as required for UM, QA, etc. and to identify provider education opportunities. 
· Responsible for monitoring the effectuation of all resolution/outcomes resulting from the appeals, Administrative Law Judge, and Medicare Appeals Council processes. 
· Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution, quality improvement, network contracting, policies and procedures, administrative costs, cost saving opportunities, best practices, and performance issues. 
· Serve as liaison with medical groups and network physicians to ensure timely resolution of cases; collaborate and partner with internal departments for resolution and education, work with physicians, hospitals and internal staff to gather information needed to resolve complex claim issues. 
· Perform other tasks, projects, etc. as needed or directed
Requirements:
Minimum Qualifications
· Associate’s degree required, Bachelor’s preferred. 
· In lieu of degree, equivalent education and/or experience may be considered. 
· 3+ years of related, professional work experience required.
· 2 years’ experience in Medicare Managed Care preferred. 
· Experience in a managed care/compliance environment preferred. 
· Knowledge of medical terminology, provider reimbursement, medical coding, coordination of benefits and all types of medical claims required. 
· Solid understanding of member and provider rights and responsibilities, particularly with appeals and grievance required.
· Familiarity with managed care, state and federal regulations is required.
· Prior auditing experience preferred. 
· Customer Service experience preferred.
· Knowledgeable in medical terminology and have prior ACD experience.
· Demonstrates good judgment, organization and prioritization skills and time management skills.
· Proven leadership with staff, projects, and management.
· Strategic thinking abilities and analytical skills
· Ability to clearly present written information and findings, concisely communicate concepts and make executive-level presentations.
 
Professional Competencies
· Integrity and Trust
· Customer Focus
· Functional/Technical Skills
· Written/Oral Communications
· Critical/Analytical Thinker
 
Verda cares deeply about the future, growth, and well-being of its employees. Join our team today!
 
Job Type: Full-time
Benefits:
<ul>
<li>401(k)</li>
<li>Paid time off (vacation, holiday, sick leave)</li>
<li>Health insurance </li>
<li>Dental Insurance</li>
<li>Vision insurance </li>
<li>Life insurance</li>
</ul>
Schedule:
<ul>
<li>Full-time onsite (100% in-office)</li>
<li>Hours of operations: 9am – 6pm</li>
<li>Standard business hours Monday to Friday/weekends as needed</li>
<li>Occasional travel may be required for meetings and training sessions.</li>
</ul>
Ability to commute/relocate:
<ul>
<li>Reliably commute or planning to relocate before starting work (Required)</li>
</ul>
PHYSICAL DEMANDS
Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds.
*Other duties may be assigned in support of departmental goals.

18 grievance-and-appeals-representative Jobs