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Program/Policy Analyst Sr (Medi-Cal Compliance) CalOptima CalOptima Health is seeking a highly motivated Program/Policy Analyst Sr (Medi-Cal Compliance) to join our team. The Program/Policy Analyst Sr (Medi-Cal Compliance) will coordinate and maintain CalOptima Health's relationship with regulatory agencies and ensure CalOptima Health and its First Tier, Downstream and Related Entities (FDRs) comply with all appropriate standards, regulations, contractual provisions, federal waivers and laws. Specifically, the incumbent works to enhance and strengthen CalOptima Health's policy infrastructure, platform and strategies at the state level, including contract compliance, statutory and regulatory obligations with the Department of Health Care Services (DHCS). The incumbent requires the ability to complete a variety of independent detailed analyses, including the development, review and response to corrective action plans. The incumbent will be responsible implementing Corrective Action Plans (CAPs), supporting regulatory audits, validating regulatory guidance and developing regulatory communications for CalOptima Health stakeholders. The incumbent will interact with CalOptima Health's executives and department management, FDR's management, legal counsel and state and federal regulatory agencies. The incumbent will also support other key CalOptima Health staff on related projects. Position Information: 
<ul>
<li>Department: OOC - MediCal Regulatory Affairs &amp; Compliance </li>
<li>Salary Grade: 311 - $77,863 - $124,581 ($37.43 - $59.8947) </li>
<li>Work Arrangement: Full Telework **This position is eligible for telework in California.** </li>
</ul>
 Duties &amp; Responsibilities: 
<ul>
<li>85% - Program Support
<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>Works with all of CalOptima Health's departments in response to inquiries, problem-solving and promoting CalOptima Health's mission and message.</li>
<li>Assists in the management of CalOptima Health's daily relationship with the DHCS for CalOptima Health's Medi-Cal program.</li>
<li>Maintains open lines of communication to ensure the ongoing trust and confidence of regulators in the program and management.</li>
<li>Researches, analyzes and makes recommendations regarding the policy implications of major initiatives for CalOptima Health's Medi-Cal program, e.g., integration of new benefits and populations.</li>
<li>Works with business areas at all levels of leadership to validate regulatory communications from regulators impacting CalOptima Health's Medi-Cal program.</li>
<li>Supports process improvements for the Office of Compliance department.</li>
<li>Serves as a Medi-Cal regulatory subject matter expert and lead for CalOptima Health's compliance issues and investigations.</li>
<li>Supports management in the readiness, coordination, oversight and remediation of regulatory audits, including but not limited to validating business area submissions, additional audit requests and written daily reports.</li>
<li>Researches and responds in a professional manner to questions pertaining to the Medi-Cal program.</li>
<li>Works with the director and manager with interactions and responses to regulatory representatives on compliance-related issues as needed.</li>
<li>Reviews and retains working knowledge of Medi-Cal policies and procedures related to assigned programs and projects.</li>
<li>Assists in the creation of communications and strategic alliances with regulators.</li>
<li>Researches and keeps current on the local, state and federal health care environment and health policy, identifying issues that may impact CalOptima Health's Medi-Cal program.</li>
<li>Coordinates the maintenance of public program benefit updates for accurate and consistent application by CalOptima Health and its provider community.</li>
<li>Participates and represents CalOptima Health in meetings and calls with regulators and associations and summarizes key points and impact to CalOptima Health's Medi-Cal program as needed. </li>
<li>10% - Administrative Support</li>
<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>Initiates, facilitates and promotes activities to foster compliance awareness and encourages the reporting of compliance issues within the organization and related entities. </li>
</ul>
</li>
<li>5% - Other
<ul>
<li>Completes other projects and duties as assigned.</li>
</ul>
</li>
</ul>
 Minimum Qualifications: 
<ul>
<li>Bachelor's degree in health services administration, public health, public policy or a related field PLUS 4 years of experience in government, public or government affairs role in health care compliance or health plan requirements 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>
</ul>
 Preferred Qualifications: 
<ul>
<li>Master's degree. </li>
<li>Experience working with regulatory agencies in California. </li>
<li>Experience with Medi-Cal regulatory requirements and/or compliance in the areas of Customer Service, Grievance &amp; Appeals, Quality Improvement, Case Management, Claims Administration and/or Utilization Management. </li>
<li>Certification in Healthcare Compliance (CHC) or other compliance related certifications such as Certified Compliance and Ethics Professional.</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=6296744&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 June 25, 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/6296744" target="_blank">https://jobs.caloptima.org/jobs/program-policy-analyst-sr-medi-cal-compliance-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-c10c0223e159b943b7243c210753f920

Program/Policy Analyst Sr (Medi-Cal Compliance)

Director, Medicare Program Development (Director III) CalOptima CalOptima Health is seeking a highly motivated Director, Medicare Program Development (Director III) to join our team. The Director III (Medicare Program Development) will be responsible for leadership, plan management and operations of CalOptima Health's Medicare lines of business, including the Program of All Inclusive Care for the Elderly (PACE) health plan operations. The incumbent will provide direction to CalOptima Health's departments to ensure compliance with regulatory agencies such as the Centers for Medicare and Medicaid (CMS), Department of Health Care Services (DHCS) and Department of Managed Health Care (DMHC). The incumbent will collaborate with the Operations Management, Clinical Operations, Regulatory Relations and Finance departments, including but not limited to Customer Service, Grievance and Appeals, Medical Management, Provider Network Operations, Strategic Development, Compliance and Regulatory Affairs and subcontracted providers and health networks. The Director III will interact with all levels of CalOptima Health's staff, members, providers, regulatory agencies, advisory committees and representatives of other agencies as needed. Position Information: 
<ul>
<li>Department: Operations Management </li>
<li>Salary Grade: 322 - $192,386 - $307,817 ($92.49 - $147.9891) </li>
<li>Work Arrangement: Partial Telework **This position is eligible for telework in California.** </li>
</ul>
 Duties &amp; Responsibilities: 
<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>Hires, supervises, develops, counsels and reviews the performance of department staff.</li>
<li>Supports the development of reports and presentations to CalOptima Health's Board of Directors, as needed.</li>
<li>Utilizes matrix management, directs and coordinates staff throughout the organization in the implementation of strategic work plans, development and implementation of new benefits or other initiatives for health plan operations, including but not limited to CMS Five Star Program operational initiatives and improvement activities.</li>
<li>Ensures implementation of Medicare and PACE program changes to comply with CMS regulatory requirements and is responsible for communication with stakeholders to implement such changes.</li>
<li>Ensures timely filing and compliance with CMS reports and data submissions.</li>
<li>Reviews and recommends approval of OneCare program and PACE health plan operations policies and procedures by the Executive Director and executive leadership. </li>
</ul>
</li>
<li>45% - Program Oversight
<ul>
<li>Directs and leads all business operations associated with the Medicare lines of business operations and supports certain PACE health plan operations, including coordination with and oversight of delegated health networks, contracted providers and contracted vendors.</li>
<li>Directly leads Medicare Programs outreach and retention function including developing strategies designed to expand community outreach and retention of current OneCare members.</li>
<li>Reviews and monitors Medicare programs and PACE program financial performance, provides recommendations and develops action plans.</li>
<li>Develops and monitors strategies and tactics for business development, new member enrollment and member retention in Medicare and PACE programs.</li>
<li>Supports Medicare annual bid submissions, including project management, supplemental benefit development and coordination with external actuary firm(s) and internal departments to complete and submit bids on time for Medicare and PACE programs.</li>
<li>Oversees the development of strategic plans, work plans and other initiatives for the OneCare and PACE program health plan operations.</li>
<li>Collaborates with Finance and other departments to improve activities for Medicare Risk Adjustment Factor (RAF) improvement activities for applicable programs.</li>
<li>Collaborates with internal departments in the implementation and oversight of community and member outreach activities designed to maximize visibility of Medicare programs including OneCare and PACE.</li>
<li>Partners with staff from across the organization to research specific issues as necessary to develop and analyze solutions and make policy or programmatic recommendations to address operational issues.</li>
<li>Reviews reports for submission to CMS, CalOptima Health's Board of Directors, executive leadership and others, as needed.</li>
<li>Facilitates monthly operations meetings to review Medicare and PACE program medical, financial and administrative operations.</li>
<li>Communicates the plan's operational issues, ensures adherence to work plans, identifies problem areas and develops solutions to issues or problems.</li>
<li>Collaborates with Medicare Programs Sales and Marketing and Communications departments in the development of marketing and enrollment strategies and tactics for increasing Medicare and PACE program enrollment and retention. </li>
</ul>
</li>
<li>5% - Completes other projects and duties as assigned. </li>
</ul>
 Minimum Qualifications: 
<ul>
<li>Bachelor's degree in business administration or related field PLUS 7 years of experience in a management position of a health insurance plan, Independent Physician Association (IPA), managed care organization or public agency serving Medicare and Medicaid (Medi-Cal) populations 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 progressive leadership experience, including direct supervision of staff required.</li>
</ul>
 Preferred Qualifications: 
<ul>
<li>Master's degree. </li>
<li>Medicare Advantage health plan operations, Medicare Advantage health maintenance organization (HMO) special needs plans (SNP), Medicaid or Medi-Cal and PACE program operations experience. </li>
<li>Project management experience.</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=6281703&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 June 20, 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/6281703" target="_blank">https://jobs.caloptima.org/jobs/director-medicare-program-development-director-iii-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-7afb9ea777e68d4fab491cabeb4bb238

Director, Medicare Program Development (Director III)

<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
Job Title: Remote Member Services Representative
Pay: $18 an hr | Bi-weekly
Job Type:
<ul>
<li>Remote in Oklahoma</li>
</ul>
Shift Options:
<ul>
<li>8AM-5PM M-F CST</li>
</ul>
Remote Member Services Representative Overview:
<ul>
<li>
Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors. Triages resulting rework to appropriate staff. • Documents and tracks contacts with members, providers, and plan sponsors. The CSR guides the member through their members plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines. • Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion for our members' best health. • Taking accountability to fully understand the member’s needs by building a trusting and caring relationship with the member. • Anticipates customer needs. Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc. • Uses customer service threshold framework to make financial decisions to resolve member issues. • Explains member's rights and responsibilities in accordance with contract. • Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system. • Educates providers on our self-service options; Assists providers with credentialing and recredentialing issues. • Responds to requests received from Aetna's Law Document Center regarding litigation; Lawsuits. • Handles extensive file review requests. • Assists in preparation of complaint trend reports. Assists in compiling claim data for customer audits. • Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals. • Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management. • Performs review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible. Performs financial data maintenance as necessary. • Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.
</li>
</ul>
Remote Member Services Representative Qualifications:
<ul>
<li>•Must live in Oklahoma</li>
<li>High School or GED equivalent. • Customer Service experiences in a transaction-based environment such as a call center or retail location preferred, demonstrating ability to be empathetic and compassionate. • Experience in a production environment.</li>
</ul>
Remote Member Services Representative Benefits:
<ul>
<li>Benefits are available to full-time employees after 90 days of employment and include health, optical, dental, life, and short-term disability insurance.</li>
<li>A 401(k) with a company match is available for full-time employees with 1 year of service on our eligibility dates.</li>
</ul>
How to Apply:
If you are interested in this position, please apply OR submit your resume to:
Saw Hlaing | <a href="mailto:shlaing@alinestaffing.com" target="_blank">shlaing@alinestaffing.com</a> | 412-790-5425

Remote Member Services Representative (Must live in Oklahoma)

<h3>Job Description</h3>
Job DescriptionCompany Description 
At Discovery Behavioral Health, we know the best way to predict the future of healthcare is to create it.&nbsp; As a member of our growing team, you will have a voice in the creation of life-changing programs and treatment centers nationwide.&nbsp; Working collaboratively with the best and the brightest in our industry, you will be part of an innovative team of professionals committed to generating positive and remarkable outcomes for the clients we serve.
If you are looking for an organization that thrives on growth, celebrates diversity of thought, and rewards passionate execution, you’ve come to the right place.&nbsp; Because we put clients first, it is our honor to support and reward those who serve them.
Compensation&nbsp;Range: $21-23 per hour
Compensation&nbsp;will be dependent upon geographic region, education, and experience.
Our Offer to You! We are dedicated to empowering our clinicians with their professional and personal development by providing:&nbsp;&nbsp; •&nbsp;&nbsp;&nbsp; 401(k) •&nbsp;&nbsp;&nbsp; Healthcare benefits&nbsp; •&nbsp;&nbsp;&nbsp; Vacation and sick days •&nbsp;&nbsp;&nbsp; Employee referral program •&nbsp;&nbsp;&nbsp; Employee discounts to various stores, amusement parks, events, etc. •&nbsp;&nbsp;&nbsp; Continuing education (CE) programs and training •&nbsp;&nbsp;&nbsp; Weekly training opportunities&nbsp; •&nbsp;&nbsp;&nbsp; Advancement opportunities within the organization&nbsp;
Job Description 
The Appeals Support Representative role directly supports the Clinical Appeals Specialist in the administrative functions of Denials and Appeals within the Utilization Review Team.
This is a full-time remote position that will work&nbsp;Monday through Friday, 8:00am-4:30pm EST or 8:30-5:00pm EST.
Responsibilities: • Complete outbound calls to payers for status updates on retro authorization requests and appeal submissions. • Interact with third party insurance representatives and utilize online sites to review retro authorization and appeal status. • Track and confirm weekly status updates on all outstanding appeal cases until final resolution. • Request, track, and receive payer correspondence regarding approvals and denials to include acknowledgment letters and determination letters. • Organize and scan all payer determination letters in KIPU charting system and update the Clinical Appeals Specialist within 24 hours of receipt. • Document final appeal outcomes as well as case details in KIPU chart system and appeal spreadsheet. • Responsible for obtaining patient and/or guardian signatures on required payer consent forms. • Submit retro authorization requests, provide support for retro SCA projects, and follow up on retro auth submissions until final resolution. • Identify problem cases and escalate issues to Clinical Appeals Specialist as appropriate. • Attend and participate in all monthly UR Team meetings and all quarterly Denials meetings. • Adhere to privacy and HIPAA guidelines. • Perform and/or assist with special projects as assigned.
Qualifications 
• Associate’s degree required or High School Diploma plus 5-7 years of appeals and grievance experience; Bachelor’s degree preferred. • Ability to work Monday through Friday, 8:00am-4:30pm or 8:30am-5:00pm EST. • Ability to utilize and navigate Zoom and Microsoft Teams for remote meetings and IM chat. • Strong Microsoft Office skills (Excel, Word, Outlook) • Experience with insurance follow up and/or appeals and grievances required. • Familiarity with medical billing, provider relations, and/or healthcare office experience required. • Ideal candidate must be a self-starter with strong attention to detail, the ability to multi-task, a high level of organization, and excellent communication skills. • Ability to remain flexible and adapt to changing situations. • Excellent customer service skills and strong analytical skills.
Not sure if you meet all the qualifications? Apply anyway! To provide truly innovative care, we need to have a diverse team around us. That’s why Discovery Behavioral Health is committed to creating an inclusive environment. If you find yourself meeting some but not all the above, we’d be happy to consider your application.
 Additional Information 
We are proud to be an EEO employer M/F/D/V. We maintain a drug-free workplace and perform pre-employment substance abuse testing.&nbsp;All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, or national origin.
For more information about our company benefits, please visit us at discoverybehavioralhealth.com/careers/
#DBH123
Discovery Behavioral Health seeks to build a diverse staff that is reflective of the patients we serve and the communities where we work. DBH encourages multiple perspectives, experiences, and strives to hire and retain a diverse workforce.

Appeals Support Representative

<h3>Job Description</h3>
Job DescriptionAre you detail-oriented, bilingual in English and Spanish, and passionate about supporting people through complex issues? We’re looking for three dedicated professionals to join our Grievance &amp; Appeals team on a 6-month hybrid assignment that makes a real impact in people’s lives. What You’ll Do: Help ensure compliance with grievance and appeal regulations from CMS, DHCS, and DMHC. Support the investigation and resolution of member and provider concerns with care and accuracy. Draft clear, timely letters and documentation to stakeholders. Coordinate across departments to ensure timely resolution of cases. Speak directly with members to gather information and answer questions. Use LEAN principles to make our work more efficient and effective. What You Bring: Bilingual fluency in English and Spanish (written and spoken). At least 3 years of office administrative experience, including proficiency with Microsoft Office. Strong typing (45+ WPM), data entry, and organizational skills. A courteous phone manner, the ability to juggle multiple priorities, and a keen attention to detail. A team-first attitude, cultural sensitivity, and a willingness to learn and follow procedures. A high school diploma or GED. Why You’ll Love Working With Us: You’ll be part of a supportive team, working in a meaningful role that helps protect members' rights and improve service across the organization. You’ll gain valuable experience in regulatory compliance, member relations, and healthcare operations—all while being part of something bigger. EEO/AA Employer/Vet/Disabled. The Know Your Rights poster is available here: <a href="https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12.pdf" target="_blank">https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRi…</a> The pay transparency policy is available here: <a href="https://www.dol.gov/sites/dolgov/files/ofccp/pdf/pay-transp_%20English_formattedESQA508c.pdf" target="_blank">https://www.dol.gov/sites/dolgov/files/ofccp/pdf/pay-transp_%20English_…</a> For temporary assignments lasting 13 weeks or longer, the Company is pleased to offer major medical, dental, vision, 401k and any statutory sick pay where required. We are committed to working with and providing reasonable accommodations to individuals with disabilities. If you need a reasonable accommodation for any part of the employment process, please contact your staffing representative who will reach out to our HR team. AppleOne participates in the E-Verify program in certain locations as required by law. Learn more about the E-Verify program. <a href="https://e-verify.uscis.gov/web/media/resourcesContents/E-Verify_Participation_Poster_ES.pdf" target="_blank">https://e-verify.uscis.gov/web/media/resourcesContents/E-Verify_Partici…</a> We also consider qualified applicants regardless of criminal histories, consistent with legal requirements. Pursuant to applicable state and municipal Fair Chance Laws and Ordinances, we will consider for employment-qualified applicants with arrest and conviction records. For Los Angeles, CA applicants: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. #1062 Company DescriptionThis company offers growth and a great group of people to work with. 
<h3>Company Description</h3>
This company offers growth and a great group of people to work with.

Medical Customer Service Representative

<h3>Job Description</h3>
Job DescriptionDescription:
 
Purpose:
The Student Services Advisor is responsible for the overall support of the Student Services Department providing day-to-day support and direction with respect to policies, practices, systems and community support. The Student Services Advisor supports 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:
Senior Student Services Manager
 
Responsibilities:
<ul>
<li>Represent and support 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 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 support with Title IX compliance</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>Address complaints and conducts investigations as directed by the Senior Student Services Manager</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 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 ONSITE Monday-Friday.
Location: 9250 NW 36th St, Miami, FL 33178.
**BILINGUAL IN ENGLISH AND CREOLE IS REQUIRED**
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 7,000 members in this year! 
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 and become a catalyst for positive change in the lives of our members. At Solis, you will be part of a locally rooted organization deeply committed to understanding and serving our communities. If you are eager to embark on a purpose-driven career that promises growth and the chance to make a significant impact, we encourage you to explore the opportunities available at Solis Health Plans. Join us and be the difference!

Member Services Representative (Bilingual in Creole)

<h3>Job Description</h3>
Job Description
 
Position Summary: The Behavioral Health Medical Director will provide clinical expertise to Community Care Plan (CCP), working closely with all the clinical departments. The Behavioral Health Medical Director will provide insight and support to Quality, Care Coordination, Pharmacy and Community Health. They will help develop internal policies and workflows for CCP. and will also oversee the utilization management processes for the behavioral health including the Severe Mental Illness (SMI) population within Florida Medicaid Managed Care. This role requires a dynamic leader with extensive experience in behavioral health, particularly in managing and optimizing care for individuals with SMI. The Medical Director will ensure that all utilization management activities align with state regulations, Medicaid policies, and best practice standards while improving care quality and outcomes for members.
Essential Duties and Responsibilities:
<ol>
<li>Clinical Oversight and Leadership:
<ol>
<li>Clinical Expertise and support for various Managed Care departments:
<ol>
<li>Assists in the growth and development of the Case Management Program providing clinical expertise to Care Coordination process. Participating in State mandated care management meetings.</li>
<li>Ensure clinical practices and decisions adhere to evidence-based guidelines and standards of care.</li>
<li>Reviews and monitors Grievance and Appeals cases serving as a resource for G&amp;A Team</li>
<li>Reviews and monitors Risk Management PQI’s and Adverse events serving as a resource for Risk Management.</li>
<li>Participates in Root Cause Analysis of specific member events.</li>
</ol>
</li>
<li>Ensures that appropriate utilization decisions are implemented:
<ol>
<li>Develops, implements, and monitors the Utilization Review Plan.</li>
<li>Develops and monitors utilization and quality improvement reporting mechanisms.</li>
<li>Develops practice guidelines for high volume diagnoses or specific instances for the populations we serve, in conjunction with the appropriate specialists.</li>
<li>Educates external physicians and staff about utilization practices to promote high quality, cost-effective care.</li>
<li>Develops written policies for the resolution of utilization problems.</li>
<li>Plans and conducts interventions with outlier physicians.</li>
<li>Recommends needed physician, facility and/or ancillary contracts to the Director of Provider Operations.</li>
<li>Conducts in-patient conferences with Utilization Management Manager/Supervisors to monitor the patient care activities weekly.</li>
<li>Acts as a resource for the Utilization Review Nurses.</li>
<li>Reviews frequent or unusual referral reports.</li>
<li>Reviews all referrals that have potential for denial of services.</li>
<li>Ability to perform Peer to Peer conversations with external physicians and staff that are providing services for our members.</li>
<li>Interfaces with Community Care Plan medical directors as needed on utilization issues.</li>
<li>Provides report to Medical Operations and engages with practices for over and underutilization in specific populations.</li>
<li>Attends all meetings, as needed.</li>
</ol>
</li>
</ol>
</li>
<li>Quality Improvement:
<ol>
<li>Develop and implement quality improvement initiatives aimed at enhancing care delivery and outcomes for all members with a focus on SMI population.</li>
<li>In partnership with Provider Operations, monitors the results of the Satisfaction Surveys and implements corrective action, when necessary.</li>
<li>Collaborate with quality management teams to assess and address performance metrics and clinical outcomes.</li>
</ol>
</li>
<li>Compliance and Regulatory Adherence:
<ol>
<li>Ensure compliance with Florida Medicaid Managed Care regulations, state laws, and federal guidelines related to behavioral health and SMI.</li>
<li>Conduct regular audits and reviews to ensure adherence to clinical standards and regulatory requirements.</li>
<li>Prepare and submit required reports and documentation to regulatory bodies.</li>
</ol>
</li>
<li>Stakeholder Collaboration:
<ol>
<li>Work closely with interdisciplinary teams, including behavioral health providers, case managers, and other healthcare professionals, to coordinate and optimize care for Medicaid members with a focus on SMI population.</li>
<li>Engage with external stakeholders, including community organizations and advocacy groups, to support integrated care initiatives and resource development.</li>
</ol>
</li>
<li>Education and Training:
<ol>
<li>Provide training and support to utilization management staff, clinical teams, and other stakeholders on best practices and emerging trends in behavioral health and SMI care.</li>
<li>Stay abreast of advancements in behavioral health treatments and methodologies and integrate them into the utilization management framework.</li>
</ol>
</li>
<li>Strategic Planning and Development:
<ol>
<li>Contribute to the strategic planning and development of behavioral health programs and services tailored to the needs of the SMI population.</li>
<li>Analyze utilization data and trends to inform strategic decisions and resource allocation.</li>
</ol>
</li>
<li>Professional and Personal Conduct:
<ol>
<li>Works at maintaining a good rapport and a cooperative working relationship with health plans, physicians, and office staff.</li>
<li>Represents Community Care Plan in a positive and professional manner in the community.</li>
<li>Always maintains patient and organizational confidentiality.</li>
</ol>
</li>
</ol>
This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.
Qualifications: 
Education and Licensure:
<ul>
<li>Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited institution.</li>
<li>Board certification in Psychiatry or a related field.</li>
<li>Valid and unrestricted medical license in the state of Florida.</li>
</ul>
Experience:
<ul>
<li>Minimum of 7 years of clinical experience in behavioral health, with a focus on severe mental illness.</li>
<li>At least 3 years of experience in a leadership role, such as Medical Director, Clinical Director, or similar position, within a managed care or Medicaid setting.</li>
<li>Proven experience with utilization management and quality improvement processes in behavioral health.</li>
</ul>
Skills and Abilities:
<ul>
<li>Strong understanding of Medicaid Managed Care and SMI-specific care requirements.</li>
<li>Computer Literacy – ability to work on multiple EHR platforms and Microsoft programs such as Word, Excel, and Power Point.</li>
<li>Excellent leadership, communication, and interpersonal skills.</li>
<li>Ability to analyze complex data and make informed decisions.</li>
<li>Demonstrated ability to work collaboratively with diverse teams and stakeholders.</li>
</ul>
Work Schedule:
 
 Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.
 
Physical Demands: 
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee may occasionally be required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.
Work Environment: 
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.
We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion.

Medical Director- Behavioral Health

<h3>Job Description</h3>
Job Description
Overview
Are you looking for a career you can feel good about? We hire only those that strive to do their best. By joining our family, you'll receive the honor and recognition that comes with working for the industry's global leader in evidenced based rehabilitation.
Who We Are:
GEO provides complementary, turnkey solutions for numerous government partners worldwide across a spectrum of diversified correctional and community reentry services. From the development of state-of-the-art facilities and the provision of management services and evidence-based rehabilitation to the post-release reintegration and supervision of individuals in the community, GEO offers fully diversified, cost-effective services that deliver enhanced quality and improved outcomes.
Why Work for GEO:
<ul>
<li>At GEO, we believe that diversity in our workforce and the inclusion of a variety of views, perspectives, and backgrounds are integral parts of our company's success.</li>
<li>We believe that work is more than a place you go every day. It is about being inspired and motivated to achieve extraordinary things.</li>
<li>Employee benefits play an important role in making The GEO Group a great place to work. At GEO, we believe in the three pillars of employee wellbeing: physical, emotional, and financial. With comprehensive benefits and competitive wages, we trust that you will find all the resources you need here to be successful.</li>
</ul>
 
Responsibilities
Summary
This position focuses on serving the needs, concerns and objectives of both managers and our employees through building effective partnerships and by creating trust and mutual respect. It leads the administration and implementation of Human Resources (HR) policies, programs and practices throughout the facility and acts as the liaison between the facility management and Regional/Corporate HR.
Primary Duties and Responsibilities
<ul>
<li>Serves as an advisor to the Facility Administrator and facility management on Human Resources issues.</li>
<li>Supports local recruiting and outreach efforts in coordination with the centralized recruiting team to meet or exceed monthly and annual recruiting targets in the most efficient and effective manner possible. Ensures a positive candidate and hiring manager experience. Prepares and maintains personnel records and ensures compliance to procedures for controlling personnel transactions and reporting personnel data. Administers and tracks employee developmental training.</li>
<li>Assists, coaches and provides guidance for progressive discipline, standards of employee conduct and employee terminations.</li>
<li>Supports reporting serious staff misconduct to the Office of Professional Responsibility (OPR).</li>
<li>Engages employees and acts as a conduit to provide facility management, Regional HR and Corporate HR insight into employee concerns.</li>
<li>Responsible for employee onboarding to include data entry into the HR Information system and new employee orientation. Ensures that data entered is accurate and employees have a thorough understanding of Company policies and procedures, to include the information included in the employee handbook.</li>
<li>Responsible for maintaining records of insurance coverage, retirement plans, and personnel transactions such as hires, promotions, transfers, performance reviews, terminations, and other related personnel and payroll issues.</li>
<li>Serves as EEO specialist and maintains affirmative action plan.</li>
<li>Serves as subject matter expert for leaves of absences, FMLA and ADA issues.</li>
<li>Ensures compliance with Company policies and procedures and develops a thorough understanding of Corporate HR policies and procedures.</li>
<li>Reviews facility personnel procedures to ensure that they are applicable, effective, and comply with contract requirements, local, state and federal law, and Company policies, procedures.</li>
<li>Resolves employee personnel inquiries and submits necessary inputs, changes, additions and deletions into the HR Information System for correction. Refers unusual or unresolved problems to Regional HR for further action.</li>
<li>May manage an assigned human resources staff and perform the duties typically associated with a management level position including hiring, training, and employee development.</li>
<li>Coordinates grievance and disciplinary hearings and activities.</li>
<li>Coordinates benefit programs, annual enrollment, and employee wellness program at facility..</li>
<li>Monitors unemployment claims, assists with appeals and may attend hearings as the Human Resources representative.</li>
<li>Partners with facility management to ensure the performance appraisal program is compliant and effective.</li>
<li>Provides guidance on compensation, bonuses and other recognition programs.</li>
<li>Monitors and coordinates workers’ compensation claims and may compile information to file workers’ compensation claims for employees and for the insurance carrier.</li>
<li>Provides necessary referral support for the Employee Assistance Program (EAP).</li>
<li>Performs other duties as assigned.</li>
</ul>
 
Qualifications
Minimum Requirements
<ul>
<li>High school diploma with a minimum of seven (7) years of progressive professional experience in Human Resources or a Bachelor’s degree from an accredited college or university in Human Resources or related field with five (5) years of experience working in a Human Resources position.</li>
<li>Must be at least twenty-one (21) years of age.</li>
<li>Three (3) years supervisory experience preferred.</li>
<li>Must exhibit leadership qualities to gain the respect of all employees and be able to display confidence when interacting with people at all levels of management.</li>
<li>Must have the ability and desire to work in a cooperative manner and to make management decisions.</li>
<li>Experience working with an HR Information System required.</li>
<li>Must be able to maintain confidentiality at all times due to the handling of sensitive and confidential information.</li>
<li>Must have the ability to communicate effectively, both verbally and in writing.</li>
<li>Must have proficiency in Microsoft Office suite (Windows, MS Word, Excel, and PowerPoint) and other computer programs and software normally used by HR.</li>
</ul>
GEO Secured Services

17 grievance-and-appeals-representative Jobs