<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 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 DescriptionSummary Description:
The Pharmacy Technician works closely with Western Health Advantage’s (WHA) Chief Pharmacy Officer, Pharmacy Manager, Medical Directors, Clinical Pharmacists and Pharmacy Coordinator to ensure pharmacy utilization management review functions are carried out effectively at the health plan level. The Pharmacy Technician may work with several internal departments to assist with pharmacy related benefit interpretation, provide pharmacy related assistance, and provide problem solving on appeal and grievance cases as needed. This position also evaluates and performs utilization review of prescription medication requests under the protocols and criteria developed by the Chief Pharmacy Officer, Pharmacy Manager and Clinical Pharmacists. This position assists in creating as well as updating and maintaining current written procedures for the team.
Representative Duties:
• Perform authorization review of prescription medication requests utilizing established protocols and criteria developed by the Pharmacy leaders and Clinical Pharmacists, transferring all clinical questions and judgements falling outside the standardized criteria to the Clinical Pharmacists for review.
• Coordinate with Pharmacy Coordinator and other internal departments to ensure authorization decisions and notifications to members and providers are completed in compliance with regulatory requirements.
• Assist Member Service Representatives and Individual Plan Administrators/Medical Group staff with interpretation of pharmacy benefits and criteria.
• Research, review, and when indicated, prepare cases for Pharmacy leaders, Pharmacist, and/or Chief Medical Officer review, and ensure timely and appropriate follow-up by creating and sending authorization/approval or denial letters.
• Assist in maintaining the WHA Formulary Drug List and Pharmacy Prior Authorization (PA) Criteria per the Pharmacy and Therapeutics (P&amp;T) Committee decisions.
• Assist Pharmacy leaders with accreditation audits by the Department of Managed Health Care (DMHC) regulatory and National Committee of Quality Assurance (NCQA).
• Assist Pharmacy leaders with pharmacy/PBM related audit tasks.
• Ensure timely creation and processing of denial letters for cases denied by Clinical Pharmacists.
• Maintain current knowledge of medications and drug classifications.
• Responsible for helping support administrative functions such as notifications to providers, members and supporting return mail process.
• Support development of Pharmacy policy procedures, training material, and desk level procedures.
• Work with the Pharmacy leaders to ensure there is appropriate coverage beyond regular business hours to ensure all cases are completed to comply with regulatory requirements.
• Experienced Pharmacy Technicians are responsible for mentoring and/or training new and less experienced Pharmacy Technicians and Pharmacy Coordinators and serve as resources in answering questions.
• Support, review, and research pharmacy related cases for Appeals and Grievances.
• Responsible for helping support administrative functions such as notifications to providers and members, and processing returned mail.
• Perform other duties and special projects as assigned.
Qualifications:
• High School Diploma.
• Three years of experience as Pharmacy Technician.
• Two years of experience working in a utilization/managed care environment.
• One year of experience working in a customer service or call center environment is highly desired.
• Must have valid California Pharmacy Technician License in good standing and must be maintained throughout employment.
• Experience with writing in business correspondence style.
• Intermediate computer skills, including electronic mail, routine database activity, word processing, spreadsheet, graphics, etc.
• Must be able to speak, read, write, and understand the primary language(s) used in the workplace.
Salary:
$21.00 - $26.00 Hourly (EOE)
 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.
 *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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Pharmacy Technician

<h3>Job Description</h3>
Job Description
Overview
*Abilis Health Plan was formerly Signature Advantage*
We are seeking a Sales Account Representative/Executive for our Abilis Health 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 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 Description
Are you looking to join a team of like-minded professionals who are passionate about serving Douglas County OHP members, engaging with the community, and delivering outstanding customer service? At Umpqua Health, we are committed to recruiting top-tier team members who provide exceptional service with professionalism, compassion, and respect for the unique needs of every individual we serve. If you thrive in a fast-paced, dynamic healthcare environment and are ready to make a meaningful impact, you may be the team member we’re looking for. We seek individuals who:
<ul>
<li>Possess genuine compassion and empathy for our members</li>
<li>Can adapt to ever-evolving healthcare regulations and requirements</li>
<li>Are motivated by challenges and dedicated to delivering superior customer service</li>
</ul>
Join us in serving over 40,000 Douglas County residents as we administer Medicaid benefits and work together to improve health outcomes in our community. Umpqua Health is a mission-driven, community-focused healthcare organization proudly serving Douglas County, Oregon. Locally owned by&nbsp;CHI Mercy Health&nbsp;and the&nbsp;Douglas County Individual Practice Association&nbsp;(DCIPA), we are deeply rooted in the region and dedicated to improving the health and well-being of our friends, families, and neighbors. Umpqua Health is the parent company of Umpqua Health Alliance, one of 16 Oregon coordinated care organizations serving the Oregon Health Plan. The Roseburg-based company and its subsidiaries are focused on expanding access, improving care, and reducing unnecessary costs across the clinical space for more than 40,000 Douglas County residents on the Oregon Health Plan and close to 10,000 more individuals with Medicare, private insurance or Exchange coverage.
Job DescriptionJOB TITLEPharmacy Technician IREPORTS TODirector of PharmacySTATUSFT, Non ExemptWAGE RANGEWage Band 13 (2024)DEPARTMENTPharmacyWORK LOCATIONRemote (occasional travel as required)&nbsp;POSITION PURPOSEAccountable for supporting medical management functions (utilization management, pharmacy management, and care coordination) with expertise in appropriate areas. Follow Umpqua Health Alliance’s policies and procedures, practice guidelines, state and federal guidelines and regulations, and other medical management resources. Serve as liaison to Oregon Health Plan members, providers, pharmacies, and community healthcare personnel.&nbsp; Works under greater supervision with guidance from more experienced staff and focuses on performing standard medical management clinical review tasks.&nbsp;ESSENTIAL JOB RESPONSIBILITIESRegulatory Compliance: 
<ul>
<li>Maintain updated knowledge of the Oregon Administrative Rules (Medicaid) governing coverage determinations.</li>
<li>Comply with organization’s internal policies and procedures, Code of Conduct, Compliance Plan, along with applicable Federal, State, and local regulations.</li>
</ul>
Utilization Review: 
<ul>
<li>Perform initial review of requests for coverage of pharmacy and medical services. Make decisions in a logical, consistent manner. Provide clear and accurate documentation of the reasoning process for decisions within allotted timeframes. </li>
<li>Effectively navigate and apply the Health Evidence Review Commission Prioritized List of Health Services.</li>
<li>Follow utilization management guidelines with few errors and consistently score 80% or above on inter-rater reliability (IRR) testing.</li>
<li>Evaluate the cost and effectiveness of proposed/delivered services before, during, and after claims payment. Analyze claims data with consideration to medical necessity, the quality of care, and the appropriateness of the delivery of care, and covered benefits.</li>
<li>Utilize applicable resources and systems to prepare materials for pharmacist review, including documentation of key findings, benefit determination, verification of codes and pricing, supporting standards citations, care plans, risk appraisals, and alternative treatment options. </li>
<li>Communicates with providers on formulary or lower cost alternatives, prior authorizations, and step therapy guidelines as well as state and federal criteria for services and supplies.</li>
<li>Perform data entry into claims adjudication system with a high level of accuracy.</li>
</ul>
Care Coordination: 
<ul>
<li>Assist with Medication Management program daily responsibilities including contacting members, pharmacies, and providers as needed to complete MedSynch and assist pharmacist with MM schedule. </li>
<li>Assist other departments in coordinating medication services for members by answering questions and resolving identified barriers.</li>
<li>Educate members and practitioners about the health plan benefit structure and relevant rights and responsibilities.</li>
<li>As needed, work with the OHP Grievance and Appeals coordinator when they receive calls from a member or the member’s representative regarding concerns about the care being provided.</li>
<li>Assisting pharmacies as needed to ensure timely dispensing of medications.</li>
<li>Other duties as assigned.</li>
</ul>
&nbsp;CHALLENGES
<ul>
<li>Working with a variety of personalities, maintaining a consistent and fair communication style.</li>
<li>Satisfying the needs of a fast paced and challenging company.</li>
</ul>
&nbsp;QUALIFICATIONSMinimum Qualifications
<ul>
<li>Current National and Oregon Certified Pharmacy Technician (CPhT) licensure.</li>
<li>1+ years' experience as a pharmacy technician.</li>
<li>Fluent in pharmaceutical and medical terminology.</li>
<li>Proficient PC navigational, MS Office (Word, Excel, Outlook), data entry, and internet research skills.</li>
<li>No suspension/exclusion/debarment from participation in federal health care programs (e.g. Medicare/Medicaid)</li>
</ul>
 Preferred Qualifications
<ul>
<li>Managed care experience.</li>
<li>Ability to provide excellent customer service to internal and external customers.</li>
<li>Effective written, verbal, and interpersonal communication skills.</li>
<li>Ability to effectively collaborate with others and function as a part of a highly functioning team.</li>
<li>Excellent self-discipline to meet deadlines and follow policies, procedures, and workflows in a remote environment.</li>
<li>Excellent critical thinking and time management skills required to organize and prioritize workload according to goals and specified turnaround times.</li>
<li>Demonstrated transferable knowledge, skills, and ability to complete job duties independently and proficiently.</li>
<li>Experience considering the impacts of the work on multiple communities, including communities of color, in technical analysis. </li>
<li>Proficient computer skills, including MS Office suite</li>
<li>Experience considering the impacts of the work on multiple communities, including communities of color, in technical analysis. </li>
<li>Experience working on a diverse team with different communication styles. </li>
<li>Bi-lingual translation or translation capabilities a plus</li>
</ul>
&nbsp;PHYSICAL DEMANDS &amp; WORK CONDITIONS
<ul>
<li>A typical office environment requires standing, sitting, walking, bending, and lifting up to 25 plus pounds.&nbsp; </li>
<li>Ability to travel and drive to in-person meetings or be on-site as required.</li>
<li>May be exposed to patient and environment conditions such as unpleasant sights, smells and contagious diseases (clinic only).</li>
</ul>
About Umpqua Health
At Umpqua Health, we're more than just a healthcare organization; we're a community-driven Coordinated Care Organization (CCO) committed to improving the health and well-being of individuals and families throughout our region. Umpqua Health serves Douglas County, Oregon, where we prioritize personalized care and innovative solutions to meet the diverse needs of our members. Our comprehensive services include primary care, specialty care, behavioral health services, and care coordination to ensure our members receive holistic, integrated healthcare. Our collaborative approach fosters a supportive environment where every team member plays a vital role in our mission to provide accessible, high-quality healthcare services. From preventative care to managing chronic conditions, we're dedicated to empowering healthier lives and building a stronger, healthier community together. Join us in making a difference at Umpqua Health. 
Umpqua Health is an equal opportunity employer that embraces individuals from all backgrounds. We prohibit discrimination and harassment of any kind, ensuring that all employment decisions are based on qualifications, merit, and the needs of the business. Our dedication to fairness and equality extends to all aspects of employment, including hiring, training, promotion, and compensation, without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, veteran status, or any other protected category under federal, state, or local law.
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<h3>Job Description</h3>
Job DescriptionOur Company Signature Advantage 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>
 About our Line of Business Signature Advantage, an affiliate of BrightSpring Health Services, is a Medicare Advantage Plan covering all the benefits of Original Medicare (Parts A and B) with prescription drug coverage (Part D). The Signature Advantage Plan is a unique plan allowing members to enroll year-round. The plan focuses on members who meet residential requirements in Signature Advantage participating nursing facilities. An interdisciplinary team of clinicians and innovative services allow us to meet each member's clinical needs and provide preventive, coordinated, and quality healthcare. With a dedicated nurse practitioner leading a personalized care plan, we strive to improve the health of the communities in which we serve. For more information, please visit <a href="http://www.signatureadvantageplan.com" target="_blank">www.signatureadvantageplan.com</a>. Additional Job Information Signature Advantage is becoming Abilis Health Plan! More information coming very soon!

<h3>Job Description</h3>
Job DescriptionDescription:
 
Purpose:
The Student Services Advisor is responsible for the overall functioning and performance of the Student Services Department providing day-to-day leadership and direction with respect to policies, practices, systems and community support. The Student Services Advisor oversees the Student Services department with respect to scheduling and work assignments, Title IX compliance, ADA coordination, student complaints, grievances, appeals and performing other duties as required. The Student Services Advisor contributes to the College’s success by providing input into the development of the campus’ strategic and operational plans, and by ensuring that the campus achieves its student engagement, retention, and completion goals in a student centric campus environment. Responsible for taking a leadership role in cultivating and creating Smith Chason College campus spirit and pride.
 
Qualifications:
<ul>
<li>Bachelor’s degree preferred. Acceptable experience includes at minimum, 2-3 years of administrative experience. Recommended competencies include:</li>
<li>Must have strong technical skills including all computer applications, internet research, database management, and analytical skills.</li>
<li>Ability to prioritize, multi-task, perform well under pressure, meet deadlines, and work flexible schedule. </li>
<li>Ability to communicate with high level industry supervisors and management teams. </li>
<li>Strong ability to work independently as well as collaboratively with other team members. </li>
<li>Ability to engage in critical thought and analyze all types of quantitative and qualitative data into reports and presentation for strategic planning and problem-solving.</li>
<li>Ability to provide support and ensure accountability for results.</li>
<li>Strong organizational skills.</li>
<li>Effective time management skills; ability to separate important issues and identify priorities.</li>
<li>Ability to track, monitor, assess and evaluate student progress and registry outcomes.</li>
<li>Possesses strong motivational skills, oral and written communication proficiency.</li>
<li>Provide excellent customer service to all members of the WCUI community.</li>
<li>Must have strong documentation skills.</li>
<li>Demonstrates integrity, credibility, confidentiality, and responsibility in all interactions.</li>
<li>Possesses high ethical standards and an honest, open, and consistent approach to working with peers, employees, employers and staff.</li>
<li>Individuals must be professional in all aspects of the position including appearance, demeanor, communication and attitude.</li>
</ul>
Reports to:
Campus Director/ Director of Education
 
Responsibilities:
<ul>
<li>Lead and represent the Department of Student Services, ensure safety of students, regulatory compliance, consistency of practice and excellent student/customer service </li>
<li>Manage the Department’s work with faculty and staff, colleagues, students and community partners to support, provide and/or facilitate activities that ensure that the campus achieves its student engagement, satisfaction, retention, and completion goals </li>
<li>Provide leadership, analysis and advisement in relation to policies, procedures, and operational plans regarding students and services for students, including risk management. </li>
<li>Monitor, manage and enforce Satisfactory Academic Progress and Attendance Policies </li>
<li>Provide a leadership role with Title IX compliance and is the campus Title IX Coordinator </li>
<li>Work with the ADA Compliance Coordinator to facilitate all communication for requests for accommodations, ensure approved accommodations are communicated and managed and support students with the grievance process </li>
<li>Ensure that the Department’s budget is planned, prepared and monitored </li>
<li>Address complaints and conducts investigations as directed by the Campus Director </li>
<li>Hire, orientate, and supervise the Student Advocate by performing such things as: direct, schedule, provide performance feedback, evaluate, suggest professional development and where necessary discipline direct reports. Manage the performance review process </li>
<li>Ensure that Student Services Department monitors students’ attendance and academic performance on a weekly basis, progress toward program completion, providing or recommending interventions as needed </li>
<li>Ensure the Student Services Department maintains appropriate documentation with regards to advising sessions including meeting overviews, progress notes, referrals, and follow-up activities. </li>
<li>Ensure that the Student Services Department follows all regulatory bodies </li>
<li>Lead in the developing and conducting of student events including but not limited to orientation, community outreach, graduation and student appreciation </li>
<li>Maintain knowledge of Smith Chason College programs, campus resources, information systems, and policies and procedures </li>
<li>Additional job-related duties as required and assigned</li>
</ul>
 
PHYSICAL REQUIREMENTS/ WORKING CONDITIONS
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
<ul>
<li>Must be able to remain in a stationary position for prolonged periods of time</li>
<li>Can independently move objects up to 25 lbs.</li>
<li>Sufficient hand, arm, and finger dexterity to operate a computer keyboard, other office machinery, and perform repetitive motions</li>
<li>Must have sufficient hearing and speaking ability to communicate in person or on the phone/computer with others</li>
<li>Must be able to occasionally function in activities that include walking, bending, squatting, and reaching</li>
</ul>
 
CULTURE OF CARE
Culture of Care is our commitment to create a supportive environment in which every student can achieve their educational and career goals. Culture of Care encourages one-on-one relationships. Creating a culture that focuses on the student and their wellness. This includes understanding the student's complex lives. It is about creating a school where everyone feels welcomed by: 
· Creating a sense of community in all interactions and communications with students 
· Identifying problem areas and offering assistance 
· Opening up safe conversations for cooperative solutions 
· Holding students to standards and goals that will ultimately make them successful in their careers
 
Requirements:

Student Services Advisor

<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

31 grievance-and-appeals-representative Jobs