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Director, Information Technology Clinical, (Utilization Management, Care Management, and Grievance &amp; Appeals) (Director IV) CalOptima Director, Information Technology - Clinical, (Utilization Management, Care Management, and Grievance &amp; Appeals) Join Us - Where Your Talent Meets Opportunity. We're Better Together The Team You'll Join We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all. More About the Opportunity We are hoping you will join us as a Director, Information Technology - Clinical, (Utilization Management, Care Management, and Grievance &amp; Appeals) (Director IV) and help shape the future of healthcare where you'll be an integral part of our IT - Applications Management team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. Together, we are building a stronger, more equitable health system. Your Contributions To the Team: 
<ul>
<li>50% - Leadership Functions
<ul>
<li>Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department.</li>
<li>Leads the development of IT strategy and technical roadmap and ensures its integration with overall IT and CalOptima Health strategies.</li>
<li>Works with the department's leadership team on the project portfolio and governance required to prioritize resources, including budget.</li>
<li>Acts as a trusted advisor and builds and maintains relationships with other internal and external IT and business leaders to develop a clear understanding of business needs. Ensures cost-effective delivery of IT services to meet those needs and can respond with the agility required to address changing business priorities.</li>
<li>Develops and adheres to the annual operating and capital budgets and expenditures for infrastructure to ensure consistency with the departmental and organizational strategic objectives and remain within budget. Manages labor forecasting in support of project cost accounting.</li>
<li>Champions innovative efforts in experimenting with new solutions to take advantage of business opportunities.</li>
<li>Stays abreast of leading-edge and innovative solutions to the recruitment, development and retention of the IT workforce. </li>
<li>Drives the adoption and commitment to continual service improvement. </li>
</ul>
</li>
</ul>
<ul>
<li>45% - Program Oversight
<ul>
<li>Provides strategic direction and oversight for the design, development, operation and support of systems that fulfill the needs of the business, including a deep understanding of the marketplace and technology's role in supporting the assigned systems.</li>
<li>Defines, develops, and manages a comprehensive and integrated architecture for assigned systems based on best-practice processes, disciplines and toolsets.</li>
<li>Operates within the established governance process to ensure that services can continue to be delivered in line with the agreed-upon business outcomes and timelines.</li>
<li>Delivers effective service management through the definition and adoption of a governance practice that uses key performance indicators (KPIs) and metrics to track and measure the quality of service. Continually monitors metrics and the integration of them with key accountabilities to ensure consistency of approach and continual service improvement.</li>
<li>Participates in the assessment of external and internal technology capabilities required to achieve desired competitive positioning.</li>
<li>Maintains knowledge of new technologies and platforms and provides direction on what emerging technologies should be assimilated, integrated, and introduced, ensuring that technology capabilities respond to and support the needs of the business.</li>
<li>Negotiates with vendor and supplier partners to enable cost-effective and innovative contracts and solutions to achieve business goals and ensure receipt of full support in line with service agreements.</li>
</ul>
</li>
</ul>
<ul>
<li>5% - Other
<ul>
<li>Completes other projects and duties as assigned.</li>
</ul>
</li>
</ul>
 Do You Have What the Role Requires? 
<ul>
<li>Bachelor's degree in computer science, information systems or other related field PLUS 7 years of experience within information technology leadership required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying. </li>
<li>7 years of experience in an IT leader role at multiple health plans required. </li>
<li>7 years of experience influencing clinical business management and key stakeholders effectively across the organization required. </li>
<li>Experience with technology and business processes required to support Utilization Management, Care Management, EMR, and other clinical tools are required. </li>
<li>Experience in leading IT transformational initiatives in dynamic environments required. </li>
<li>Experience managing staff of 20+ required. </li>
<li>Experience managing large-scale consulting/contracting engagements required. </li>
<li>Experience managing operational and project budgets (including project cost accounting) required. </li>
<li>Experience with the technology implications of a delegated provider model required. </li>
<li>Experience leading the implementation of Utilization and Care Management vendor systems and an extensive knowledge of best-in-class integrations required and optimal reporting/analytics. </li>
<li>Comprehensive knowledge of the Utilization and Care Management technology vendor marketplace and the ability to compare and contrast vendors and benefits delivered. </li>
<li>Experience crafting business cases including meticulous cost estimates and quantifiable benefits.</li>
</ul>
 You'll Stand Out More If You Possess the Following: 
<ul>
<li>Experience leading a team responsible for ZeOmega's Jiva (Utilization Management and Care Management). </li>
<li>Clinical credentials.</li>
</ul>
 What the Regulatory Agencies Need You to Possess? 
<ul>
<li>N/A</li>
</ul>
 Your Knowledge &amp; Abilities to Bring to this Role: 
<ul>
<li>Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. </li>
<li>Work independently and exercise sound judgment.</li>
<li>Communicate clearly and concisely, both orally and in writing.</li>
<li>Work a flexible schedule; available to participate in evening and weekend events.</li>
<li>Organize, be analytical, problem-solve and possess project management skills.</li>
<li>Work in a fast-paced environment and in an efficient manner.</li>
<li>Manage multiple projects and identify opportunities for internal and external collaboration.</li>
<li>Motivate and lead multi-program teams and external committees/coalitions.</li>
<li>Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.</li>
</ul>
 Your Physical Requirements (With or Without Accommodations): 
<ul>
<li>Ability to visually read information from computer screens, forms and other printed materials and information.</li>
<li>Ability to speak (enunciate) clearly in conversation and general communication.</li>
<li>Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.</li>
<li>Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.</li>
<li>Lifting and moving objects, patients and/or equipment 10 to 25 pounds</li>
</ul>
 Ways We Are Here For You 
<ul>
<li>You'll enjoy competitive compensation for this particular role:
<ul>
<li>Pay Grade: 323 - $204,199 - $326,717 ($98.17 - $157.0756) </li>
</ul>
</li>
<li>This position is approved for Partial Telework. (If the position is listed as Telework, it is eligible within California)</li>
<li>A <a href="https://apptrkr.com/get_redirect.php?id=6642622&amp;targetURL=https://www.caloptima.org/en/careers#benefits" target="_blank">comprehensive benefits package</a> </li>
<li>CalPERS pension program and additional retirement packages. </li>
<li>Additional benefits and perks including:
<ul>
<li>A generous PTO program</li>
<li>A quality work life balance</li>
<li>Various wellness programs</li>
<li>Tuition Reimbursement</li>
<li>Professional development opportunities</li>
<li>Career development opportunities</li>
<li>Flexible scheduling</li>
<li>And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.</li>
</ul>
</li>
</ul>
 Our Work Environment: If located at the 500, 505 Building or a remote work location: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.</li>
<li>There are no harmful environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate.</li>
</ul>
 If located at PACE: 
<ul>
<li>Work is typically indoors in a clinical setting serving the frail and elderly.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 If located in the Community: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. </li>
<li>Employee will occasionally work outdoors in varied temperatures.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 Why Join Us? We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impacts on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare. What's Your Next Step? All Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. Do NOT miss out. If you want to join our team, the deadline for the first review of applications is September 25, 2025 at 9:00 PM (PST). We are encouraging you to apply early. If you apply after the first review date, your application is not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. Our Commitment to You Your application and resume will be reviewed by a dedicated recruiter to this position. If your experience matches what we need, we will reach out to you to discuss the next steps. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. If you make it through the steps above and are selected for this exciting role, you will be required to undergo a reference and a background check (to include a conviction record) and if applicable also pass a drug screening and/or a post-offer pre-employment medical examination (for specific positions) If you are an Internal CalOptima Health applicant, please apply through the internal portal on InfoNet. We will make sure to keep you updated through each step of the process on your candidate portal. Please make sure to watch for updates on your candidate portal and you emails which will be sent to the email address you listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. To apply, please visit: <a href="https://apptrkr.com/6642622" target="_blank">https://jobs.caloptima.org/jobs/director-information-technology-clinical-utilization-management-care-management-and-grievance-appeals-director-iv-505-city-parkway-west-california-united-states</a> Copyright 2025 Jobelephant.com Inc. All rights reserved. <a href="https://www.jobelephant.com/" target="_blank">Posted by the FREE value-added recruitment advertising agency</a> jeid-4e4e0ade0073cc41b12e7551a09c74b4

Director, Information Technology  Clinical, (Utilization Management, Care Management, and Grievance & Appeals) (Director IV)

Social Worker (PACE) CalOptima CalOptima Health is seeking a highly motivated Social Worker (PACE) to join our team. The Social Worker for the Program for All-Inclusive Care for the Elderly (PACE) will be responsible for direct social work care management services, such as participant screening, case management, counseling and referrals of participants to PACE. Position Information: 
<ul>
<li>Department: PACEC - Social Work </li>
<li>Salary Grade: 309 - $68,015 - $108,824 ($32.70 - $52.3192) </li>
<li>Work Arrangement: Full Office </li>
</ul>
 Duties &amp; Responsibilities: 
<ul>
<li>70% - Care Management
<ul>
<li>Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Participates in the Interdisciplinary Team's (IDT) initial, six (6) month and annual assessments, as well as care planning of the participant's case in accordance with industry and departmental standards.</li>
<li>Documents participant changes appropriately in the medical record in accordance with industry and departmental standards.</li>
<li>Communicates effectively and openly with other IDT members on participant status and needs.</li>
<li>Assesses patients for high-risk situations such as suicidal/homicidal ideation and abuse. Reports appropriately in accordance with legal and ethical standards of practice and engages in safety planning with participants and/or family.</li>
<li>Develops and leads group counseling and participant support group activities.</li>
<li>Refers participants and families to appropriate community agencies or facilities, serves as a liaison with such organizations and as an advocate for participants.</li>
<li>Assists in the completion of advance directives, mortuary arrangements, funeral planning and/or facility placement.</li>
<li>Aids patients/representatives in ascertaining third-party and financial resources and planning for financial coverage for services as necessary.</li>
<li>Addresses any psychosocial needs that may require social work support and intervention (e.g., anxiety, depression and other behaviors), both at the center and at home.</li>
<li>Works with PACE participants and the IDT to develop an appropriate discharge plan for disenrolling from PACE services.</li>
<li>May be required to perform home visits to private homes of CalOptima Health's PACE participants; frequent travel in Orange County.</li>
<li>Support PACE participants with care coordination needs, such as transportation, family communication, scheduling visits to the center, supporting with warm handoff process to our community partners.</li>
<li>Represents and supports the participant's care management needs by being an advocate for their care, supporting clinical needs such as supportive counseling, developing care plans to manage all psychosocial needs (i.e., establishing support systems, coping mechanisms, assessing depression, anxiety, cognition) and developing interventions. </li>
</ul>
</li>
</ul>
<ul>
<li>25% - Support Services
<ul>
<li>Assists the team in carrying out department responsibilities and collaborates with others to support short and long-term goals/priorities for the department.</li>
<li>Consults with and advises staff members regarding the relationship of social, emotional and cultural factors to health and medical care and the availability of social services in the community.</li>
<li>Attends and participates in in-services, staff meetings and case conferences.</li>
<li>Helps support the new enrollee process of enrollment into the PACE program (e.g., communicates to IDT and ensures all service gaps are covered prior to enrollment).</li>
<li>Participates in program improvement for the Social Work department.</li>
<li>Works with the Quality Improvement (QI) department to support grievances, appeals and advocacy consistent with participant's rights.</li>
</ul>
</li>
</ul>
<ul>
<li>5% - Other
<ul>
<li>Completes other projects and duties as assigned. </li>
</ul>
</li>
</ul>
 Minimum Qualifications: 
<ul>
<li>Master's degree in social work from an accredited college or university PLUS 2 years of experience in a health-related field required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying. </li>
<li>1 year of experience working with the elderly population with relevant experience within the last 3 years required. </li>
<li>CPR and First-Aid Certification required or must be obtained within six (6) months of the date of hire. </li>
<li>Valid driver's license and vehicle or other approved means of transportation, an acceptable driving record and current auto insurance will be required for work away from the primary office 30% of the time or more.</li>
</ul>
 Preferred Qualifications: 
<ul>
<li>1 year of case management experience with the elderly population. </li>
<li>Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Russian, Spanish, Vietnamese).</li>
</ul>
 Required Licensure / Certifications: 
<ul>
<li>N/A</li>
</ul>
 Knowledge &amp; Abilities: 
<ul>
<li>Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. </li>
<li>Work independently and exercise sound judgment.</li>
<li>Communicate clearly and concisely, both orally and in writing.</li>
<li>Work a flexible schedule; available to participate in evening and weekend events.</li>
<li>Organize, be analytical, problem-solve and possess project management skills.</li>
<li>Work in a fast-paced environment and in an efficient manner.</li>
<li>Manage multiple projects and identify opportunities for internal and external collaboration.</li>
<li>Motivate and lead multi-program teams and external committees/coalitions.</li>
<li>Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.</li>
</ul>
 Physical Requirements (With or Without Accommodations): 
<ul>
<li>Ability to visually read information from computer screens, forms and other printed materials and information.</li>
<li>Ability to speak (enunciate) clearly in conversation and general communication.</li>
<li>Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.</li>
<li>Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.</li>
<li>Lifting and moving objects, patients and/or equipment 10 to 25 pounds</li>
</ul>
 Work Environment: If located at the 500, 505 Building or a remote work location: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.</li>
<li>There are no harmful environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate.</li>
</ul>
 If located at PACE: 
<ul>
<li>Work is typically indoors in a clinical setting serving the frail and elderly.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 If located in the Community: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. </li>
<li>Employee will occasionally work outdoors in varied temperatures.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 About CalOptima Health: CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! About our Benefits &amp; Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the <a href="https://apptrkr.com/get_redirect.php?id=6652797&amp;targetURL=https://alliantbenefits.cld.bz/25caloptimacabenguide" target="_blank">2025 CalOptima Health Benefits Guide</a> regarding our comprehensive benefits and wellness package. IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is October 28, 2025 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet. Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. To apply, please visit: <a href="https://apptrkr.com/6652797" target="_blank">https://jobs.caloptima.org/jobs/social-worker-pace-pace-garden-grove-california-united-states-58da0142-6a85-4436-b766-3262bc0eebfd</a> Copyright 2025 Jobelephant.com Inc. All rights reserved. <a href="https://www.jobelephant.com/" target="_blank">Posted by the FREE value-added recruitment advertising agency</a> jeid-a11aa92bce284647bad31fc069921fed

Social Worker (PACE)

<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
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 required 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-Dallas Office

<h3>Job Description</h3>
Job DescriptionSummary Description:
The Appeals &amp; Grievances Specialist I is responsible for knowledge of WHA’s practices, processes, policies and procedures, benefit guidelines, and contractual agreements. This position is also responsible for meeting all regulatory guidelines and timeframes with regards to appeal and grievance (complaint) case processing for Western Health Advantage (WHA). This includes, but is not limited to, maintaining knowledge of the CA Department of Managed Healthcare (DMHC) regulations and the National Committee for Quality Assurance (NCQA) credential standards for accreditation pertaining to appeals and grievances, as well as Privacy Practices for the Use and Disclosure of Protected Health Information (PHI) regulations, with regards to member information and medical records. This is a fast-paced position that involves extensive interaction with internal departments, external entities, to include medical groups, providers, an authorized representative, or broker.
Representative Duties:
• Serve as the assigned specialist to perform intake, research and investigation of member issues that are related to appeals and/or grievances, while effectively representing the member’s interest from initial triage.
• Quickly learn and retain appeals and grievances classifications, which include, but are not limited to, a request to change an initial decision or modification, or to grieve, with regard to enrollment/disenrollment, premium billing, access and care coordination, service, medical and prescription benefits and prior authorizations, claims processing, medical and prescription reimbursement requests, deductibles and out-of-pocket maximums, utilization management, quality of care, legal/compliance matters, or any aspect related to their health plan or its delegated entities.
• Identify urgency of a case, screening of an expedited request, recognition of a potential quality issue, violation of PHI/HIPAA, medical fraud, breach of contract or when a request exceeds the statutes of limitations.
• Perform outreach to members or authorized representative(s), when necessary, to obtain additional information and clarification in relation to the grievance/appeal.
• Promptly perform intake utilizing multiple systems for initial intake and research.
• Triage and task to next level of support or to the appropriate clinical staff for further review.
• Perform outreach and provide notification to members regarding expedited requests and whether or not it met criteria, followed by their rights to contact the DMHC.
• Work with WHA’s internal departments, contracted medical groups, and hospital systems to request all pertinent information relevant to the member’s appeal/grievance.
• Evaluate information received from appropriate departments or entities to ensure that the information provided is sufficient for a Plan determination.
• Perform follow-up on appeals and/or grievances, as assigned, and contact the appropriate departments or entities (internal or external) for a thorough response.
• Maintain accurate and thorough documentation of outreach, communications, medical records and chart notes, decisions, and appeal review committee actions.
• Customize all written acknowledgement letters to summarize the member’s request.
• Assist with resolution letters to include case specifics which are established and based on a determination of benefit guidelines and/or medical necessity, to include education to members.
• Report possible trends or increased issues when identified during intake.
• Participate and engage in process improvement plans, to include training improvement opportunities.
• Effectively communicate with team members and provide support to A&amp;G staff that have increased responsibilities.
• Provide support to the A&amp;G Coordinator, to include backup with monitoring and handling of incoming/outgoing email, mail, and faxes.
• Perform other duties and special projects as assigned
Qualifications:
• High School Diploma.
• 2 years’ experience in a similar role (appeals and grievances) in the healthcare industry; preferably HMO, with increased responsibilities.
• Experience with HMO claims adjudication, as well as referrals and authorizations (utilization management), are preferred.
• Intermediate computer skills, including electronic mail, routine database activity, word processing, spreadsheet, graphics, etc. Specifically, Microsoft Word and Excel.
• Must be able to speak, read, write (intermediate writing skills), and understand the primary language(s) used in the workplace.
Salary:
$22.00- $25.00 Hourly
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. (EOE)
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.
 *WARNING: Please beware of phishing scams that solicit interviews or promote work-at-home opportunities, some of which may pose as legitimate companies. Please be advised that Western Health Advantage will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the to the Federal Trade Commission by selecting the ‘Rip-offs and Imposter Scams’ option.’
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Appeals & Grievances Specialist I

<h3>Job Description</h3>
Job DescriptionSummary Description:
The Chief Medical Officer (CMO) is responsible for all areas of Medical Management including, but not exclusive to, Utilization Management, Quality Management, Credentialing, Medical Policy Development, and Medical Informatics. The CMO will provide leadership, management and direction for all medical management operations, reporting and contracting functions while ensuring that the Board of Directors, Chief Executive Officer (CEO), the President, and other members of the senior leadership team have constant access and timely updates relative to departmental information and analysis necessary to assist in meeting its operational goals and business objectives as set forth in the company’s strategy for growth and annual performance budget. This position carries out responsibilities in the following functional areas: Chair Quality Committee, Chair Appeals Review Meeting, Chair Peer Review Committee, Member Pharmacy Oversight Committee, Utilization Management and Quality Management meetings, ensuring compliance with requirements for confidentiality and conflict of interest, development of staff relationships, and bringing together the coalition of Medical Groups and Integrated Delivery Systems. The CMO also serves as the Chief Health Equity Officer for the plan with responsibility to ensure health equity across plan services.
Representative Duties:
• Promote and adhere to WHA’s Privacy and Information Security Programs. Ensure and verify that all department Workforce Members attend and complete mandatory training. Inform department Workforce Members that WHA will take disciplinary action up to and including termination of employment or assignment with WHA for violation of these privacy and security policies, procedures, and regulatory requirements. Also, that strict adherence to the related laws, rules, regulations, policies, and procedures is considered an integral part of their job performance and monitor compliance.
• Contribute to the strategic direction, goals and vision of the plans offered by Western Health Advantage.
• Provide clinical oversight to the Medical Management staff and remain ultimately responsible for the Utilization Management Program and the oversight of any delegated functions.
• Responsible for maintaining Compliance with all California and Federal laws and regulations as applicable.
• Responsible for developing and executing the Medical Management budget.
• Responsible for the overall quality of care program to include (but not limited to) performance review, Credentialing, Clinical Program Development, Quality Outcomes, Disease State Management, Out of Area Repatriation, Clinical Programs Management
• Develop and interpret medical policy guidelines from nationally recognized entitles, governmental, or internally developed.
• Responsible for required reporting to all WHA clients, including but not limited to, CalPERS, Covered CA, Federal Employees Health Benefits program and Employers.
• Develop data driven strategies to manage high cost / high utilizing members and effectively engage members in WHA clinical programs to improve clinical outcomes and bend Total Cost of Care.
• Responsible for oversight of all clinical aspects of the grievance/appeal system and for continuous review of appeal, complaint, and grievance data to identify emerging patterns of member dissatisfaction.
• Report on work of the Quality Improvement Committee (QIC) to the Board of Directors.
• Lead and drive efforts on Provider Integration with WHA’s Medical Groups and Hospital Partners including but not limited to Access, Quality, Cost Management and other areas as directed by CEO/President.
• Responsible for supporting and growing relationships with WHA Brokers and Employer clients
• Actively participate in WHA Board meetings, providing reports and input when directed.
• Assist and oversee clinical regulatory and accreditation audits.
• Monitor network access and recommend actions to WHA and delegated Medical Groups as.
• Establish and implement the departmental staffing plans and sound business processes to support the effective execution of the company’s business plans and strategies.
• Work collaboratively with Human Resources and Medical Management Department Team leaders to select, train, supervise, and effectively performance manage the medical management staff.
• Maintain consistently high-performance standards for all departmental staff and team members by regularly communicating business updates, coaching, counseling, disciplining and completing timely performance evaluations in accordance with the company’s HR guidelines and standards.
• Establish and execute personal and professional development initiatives for the Medical Management Department team members and their self for the purpose of keeping current and effective in the performance of their various job duties and roles.
• Perform other duties and special projects as assigned.
• Avoid and report all potential and actual conflicts that may arise in course of CMO duties per WHA’s applicable policies on Conflict and Excess Benefit Transactions.
Skills:
• Highly proficient at strategic planning and building effective company business that are directly linked to the achievement of the company’s business performance objectives.
• Has a highly proficient understanding of Federal and State and commercial regulations as dictated by both the Department of Health Services and the Department of Managed Health Care while working closely with the Chief Executive Officer as they interact with the State of California regulatory agencies and other payers.
• Possesses a working knowledge of capitation, medical risk, and HMO contracting including the role utilization plays in affecting the bottom line of the business.
• Possesses a full understanding of the company’s Business Plan envisioning multiple payers set against a complex web of federal and State regulations and policies.
• Proficient in business relevant software programs used within the Medical Management department including, Excel, Word, Outlook and Salesforce software.
• Effective public speaking, group presentations and one-on-one interactions, both internal and external to the company with a proven ability to positively influence listeners, which includes use of communications aids (i.e. charts, graphs, overheads, etc.).
• Proficient with leadership practices and processes with members of their medical management department, including administration and adherence to company policies and procedures.
• Highly effective at building rapport that encourages trust, inspires confidence and enlists cooperation with all other WHA team members and departments in a variety of work situations.
• Highly proficient at establishing credibility and maintaining effective work relationships with those contracted in the performance of required duties for the company.
• Highly proficient with oral and written communication in the primary language(s) used in the workplace, including the ability to prepare reports and business correspondence in a professional and timely manner.
&nbsp;Qualifications:
<ul>
<li>
Doctorate in Medicine or Osteopathy.
</li>
<li>
7 years’ clinical management experience.
</li>
<li>
Current License to practice medicine without restriction in the State of California required.
</li>
<li>
Must be California State Board Certified.
</li>
<li>
Highly competent 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>
<li>
Must be able to speak, read, write, and understand the primary language(s) used in the workplace.
</li>
</ul>
.
Salary: $350,000.00 - $380,000.00 Annually&nbsp;+ up to 30% bonus opportunity
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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Chief Medical Officer

<h3>Job Description</h3>
Job Description
Overview
*Signature Advantage is becoming Abilis Health Plan!*
We are 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. Regional Travel is required.
We value candidates with direct sales and account management experience, a KY or TN State Insurance License (or willingness to quickly get one), and experience working with our elder community. 
Our salary includes eligibility 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 Description
 
Under the supervision of the Call Center Manager, the Call Center Representative shall ensure that all incoming DWIHN Call Center phone calls are answered and assessed for severity in order to triage the call and provide the most appropriate services. 
PRINCIPAL DUTIES AND RESPONSIBILITIES:
<ul>
<li>Answers all phone calls using the approved telephone answering script on one of three shifts for the DWIHN 24-hour Call Center. </li>
<li>Assesses the call for crisis. </li>
<li>Conducts warm transfers for any caller in crisis to a crisis counselor. </li>
<li>Identifies and transfers callers to appropriate community resources.</li>
<li>Responds to requests from Emergency Departments.</li>
<li>Responds to requests from Emergency Departments for children’s mobile crisis teams and dispatches the appropriate team. </li>
<li>Documents all incoming telephone calls. </li>
<li>Collects demographic information on all calls. </li>
<li>Conducts warm transfers for any caller who needs a clinical assessment/screen to a Call Center Clinician. </li>
<li>Ensures all aspects of the Enrollment/Re-Enrollment process are conducted. </li>
<li>Responds to inquiries regarding enrollment and eligibility. </li>
<li>Performs enrollment changes according to The Detroit-Wayne Integrated Health Network criteria and guidelines.</li>
<li>Complies with the default CRSP assignment protocol. Assesses the Detroit Wayne Integrated Health Network MH-WIN Database for eligibility determination, look-up, enrollment, and default CRSP assignment. </li>
<li>Verifies that a consumer is a resident of Wayne County. </li>
<li>Assigns consumers to a CRSP via the Preference or Random request system. </li>
<li>Documents all calls in MH_WIN. </li>
<li>Documents all ineligible or incomplete enrollments in the MH-WIN database. </li>
<li>Conducts monthly TDD/TTY tests. </li>
<li>Gathers information regarding complaints or grievances and completes the appropriate documentation. </li>
<li>Ensures that all aspects of the Consumer Complaint, Grievance, and Appeals Process are forwarded to Customer Services. </li>
<li>Provides consumers with accurate information as to the grievance, appeal and local dispute resolution process associated with their specific benefit plan. </li>
<li>Provides information regarding the complaint management systems of the public mental health systems and the specific benefit plans.</li>
<li>Ensures that all call logs and enrollment documentation are complete before the end of the work shift. </li>
<li>Documents all compliments and complaints. </li>
<li>Notifies a supervisor immediately of consumer complaints. </li>
<li>Performs follow up calls and customer satisfaction surveys.</li>
<li>Attends monthly staff meetings.</li>
<li>Attends required trainings.</li>
<li>Performs related duties as assigned.</li>
</ul>
KNOWLEDGE, SKILLS AND ABILITIES (KSA’s) 
<ul>
<li>Knowledge of DWIHN policies, procedures and operations.</li>
<li>Knowledge of the DWIHN provider network.</li>
<li>Knowledge of medical and behavioral health practices and terminology.</li>
<li>Knowledge of Customer Service practices and principals.</li>
</ul>
<ul>
<li>Knowledge of co-occurring and substance use treatment services. </li>
<li>Knowledge of priority population admittance. </li>
<li>Knowledge of State Disability Assistance (SDA).</li>
<li>Computer skills</li>
<li>Time management skills</li>
<li>Organizational skills</li>
<li>Critical thinking skills</li>
<li>Decision Making skills</li>
<li>Customer Service skills</li>
<li>Language skills</li>
<li>Listening skills</li>
<li>Teamwork skills</li>
<li>Ability to communicate orally.</li>
<li>Ability to communicate in writing.</li>
<li>Ability to work effectively with others.</li>
<li>Ability to work with an ethnically, linguistically, culturally, economically and socially diverse population.</li>
<li>Judgement/Reasoning ability.</li>
</ul>
Required Education:
<ul>
<li>A Bachelor’s Degree from a recognized college or university in a Human Service, Social Service, Public Health, Public Administration, Healthcare Administration, Health Management or a related field.</li>
</ul>
 
Required Experience:
<ul>
<li>Two (2) years of full-time paid experience working in a human service or social service field.</li>
</ul>
Working Conditions
Work is usually performed in a home/office setting. 
Contingent staff are allowed to work remotely with management approval. 
NOTE: The DWIHN Call Center is a 24/7 operation. Employees in the Call Center may be required to work one of three shifts (Days, Afternoons, Midnights) and weekends.

This description is not intended to be a complete statement of job content, rather to act as a general description of the essential functions performed. Management retains the discretion to add or change the position at any time. 

Please Note: DWIHN requires proof of being fully vaccinated for COVID-19 as a condition of employment. Medical or religious accommodations or other exemptions that may be required by law, will be approved when properly supported. Further information will be provided during the recruitment process. 
DWIHN is an Equal Opportunity Employer

Call Center Representative Contingent

<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

<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!

28 grievance-and-appeals-representative Jobs