<h3>Job Description</h3>
POSITION OVERVIEW
This position directs the comprehensive human resources program and manages the activities of the institution’s Human Resources Office that include staff training/development, planning, organizing, developing, implementing and directing. This position will also oversee the transition of existing processes and procedures to Workday's Human Capital Management (HCM) platform. This includes the development of a new policies and procedures manual and the facilitation of staff training on the new system. Duties of this position are carried out with wide latitude, judgment and discretion.
ESSENTIAL JOB FUNCTIONS
<ul>
<li>Regularly reviews and revises human resources procedures and operations consistent with current laws and institutional policies; studies and evaluates current procedures and recommends changes including transitioning to Workday's Human Capital Management (HCM) platform</li>
<li>Represents the Human Resources department in Institutional, Collaborative for Higher Education Shared Services (CHESS), and Workday meetings, ensuring alignment and compliance with LCC’s policies.</li>
<li>Develops and maintains affirmative action program.</li>
<li>Establishes and implements short- and long-range goals, objectives, policies, and operating procedures.</li>
<li>Oversees integrity of records, reports, and logs to conform to EEOC regulations.</li>
<li>Conducts various cost analysis, relative to human resources budgetary planning control.</li>
<li>Serves as liaison with institute management and staff to discuss and resolve a variety of human resources issues such as staffing, reorganization, policy and rule interpretation and related personnel issues.</li>
<li>Plans, develops and recommends new or revised human resource policies and programs to meet the operating needs of the institution and the needs of its employees.</li>
<li>Analyzes and evaluates the impact of proposed legislation and rule changes; assists in the establishment of institutional human resources policies, rules and procedures.</li>
<li>Serves on institutional committees as representative of the Human Resources Department.</li>
</ul>
Revised 04/2024
Human Resources
<ul>
<li>Oversees collaborations with the Offices of Financial Aid, Payroll, and department supervisors for seamless student employment processes.</li>
<li>Coordinates grievance panel nominations, hearing, and activities.</li>
<li>Monitors unemployment claims and assists departments with appeals, performance appraisal programs, Workers’ Compensation claims, and posting of position announcements, interview processes, and selection of employees.</li>
<li>Complies with all institutional, federal, state, and audit reporting requirements.</li>
<li>Performs other duties as assigned.</li>
</ul>
KNOWLEDGE, SKILLS AND ABILITIES
<ul>
<li>Ability to maintain confidentiality and professionalism.</li>
<li>In-depth knowledge of human resources processes, procedures, and documentation.</li>
<li>In depth knowledge of federal, state personnel laws, regulations, and public sector employment policies and procedures including EEOC laws and regulations</li>
<li>Knowledge of alternative dispute resolution processes</li>
<li>Ability to provide effective leadership, project management, and supervision</li>
<li>Skill in examining and re-engineering operations and procedures, formulating policy, and developing and implementing new strategies and procedures</li>
<li>Strong analytical and problem-solving skills.</li>
<li>Excellent verbal and written communication skills.</li>
<li>Exceptional customer service skills and the ability to work effectively with a diverse community.</li>
<li>Proficient in mastering Workday's Human Capital Management (HCM) platform and Microsoft Office Tools including Excel.</li>
</ul>
WORK ENVIRONMENT AND PHYSICAL FACTORS
<ul>
<li>Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects. Sedentary work involves sitting most of the time.</li>
<li>The worker is required to have close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading and visual inspection.</li>
<li>The worker is not substantially exposed to adverse environmental conditions.</li>
</ul>
EDUCATION AND EXPERIENCE
<ul>
<li>Bachelor’s Degree in Human Resources or Business Administration is required or a combination of education, certification, and experience will be considered.</li>
<li>Seven to ten years in the Human Resources field is required.</li>
<li>At least two years of supervisory experience is required</li>
<li>SHRM certification is required or must be completed within the first year of employment.</li>
<li>Experience in Workday or another Enterprise Resource Platform is required.</li>
<li>Master’s degree in Human Resource Management or related Personnel/Human Resources field is preferred.</li>
</ul>
recblid sb86idfrgqcbgmg2zfk3p0kihd48tb

Human Resources Director

<h3>Job Description</h3>
Senior Member Service Representative (Hybrid; Bilingual - Spanish)
VillageCareMAX
 112 Charles Street, New York, NY 10014
COME WORK FOR THE LEADING, LOCAL MANAGED CARE COMPANY - VILLAGECARE!

Under the direct supervision of the Supervisor of Member Services, the Senior Member Services Representative is responsible for handling all calls that come through our call center. The Senior Member Services Representative will handle more complex inquiries and grievances to serve as an escalation channel to the Member Service Representative. Responsible for assisting member in accessing services, solving problems and communicating with other members of the Interdisciplinary Care Team. 
Some daily responsibilities will include:
<ul>
<li>Handles incoming telephone calls and answers questions for members and providers; assists members in accessing all necessary covered and non-covered services in conjunction with plan of care</li>
<li>Handle and provide analytical research and resolution to escalation calls.</li>
<li>Conducts post-enrollment orientation activities, including orientation of members, members' families or representatives</li>
<li>Explains the plan's rules for obtaining services and assists members in making appointments with their primary care physician and other health care providers</li>
<li>Responds to member questions and grievances; and advising members of the prerogative to complain to Department of Health or State designated entity at any time</li>
<li>Clarifies information in the member handbook or VillageCareMAX website for members</li>
<li>Advises members of the plan's grievance and appeals system, the services authorization process and the member's right to a fair hearing and/or external review; Log member and provider grievances; Resolves same day grievances where possible. </li>
<li>Facilitates communications between members, subcontractors, providers and Care Managers</li>
<li>Conducts medication reminder phone calls under the direction of the Interdisciplinary Care Team </li>
<li>Assists member in selection of participating providers</li>
<li>Assists the Interdisciplinary Care Team in performing non- clinical assessments </li>
<li>Data enterers authorizations under the direction of the Interdisciplinary Care Team</li>
</ul>

Education: Associate degree is required; bachelor's degree is preferred.
Experience: Minimum of 3 years' job related experience in Health Care; Experience with Managed Long Term Care and Medicare Dual Special Needs programs preferred; Demonstrated experience with PC's and related software including Windows and Microsoft Office Suite; Bilingual - Spanish is required. 

There are many benefits to working for VillageCare. If you are someone who likes being part of a team, enjoys a highly competitive benefits package from world leading carriers and competitive compensation, than we would love to speak with you! 
<ul>
<li>PTO package, 10 Paid Holidays, Personal and Sick time, Medical/Dental/Vision, HRA/FSA, Education Reimbursement, Retirement Savings 403(b), Life &amp; Disability, Commuter Benefits, Paid Family Leave, Additional Employee Discounts</li>
</ul>
VillageCare offers a wide range of at-home and community-based services, as well as managed long-term care options that seek to match each individual's needs to help them attain and maintain the greatest level of independent living possible. We are committed to superior outcomes in quality health care.


VillageCare is an Equal Opportunity Employer. 
Job Posted by ApplicantPro

Senior Member Service Representative (Hybrid; Bilingual - Spanish)

<h3>Job Description</h3>
Salary Range: 
Analyst/Supervisor
 Min
$ 49,920.00
Mid
 $ 62,400.00
Max
$ 74,880.00 

Summary
Richmond Redevelopment and Housing Authority’s (RRHA) Associate General Counsel to support the General Counsel in providing representation of RRHA as an institutional client. The incumbent will render legal opinions and offer legal advice to RRHA’s Board of Commissioners and its Chief Executive Officer, as well as its Department Directors and other employees, as directed. In this role, you will be responsible for conducting litigation, research, and other legal duties. Considerable initiative and independence are exercised in formulating and administering policies and procedures, under the general supervision of the General Counsel.
Essential Duties and Responsibilities
The position duties and responsibilities listed below describe the general nature and scope of work. Other responsibilities, duties, and skills may be required and assigned, as needed. 
<ul>
<li>Represents, advises, defends and counsels RRHA staff regarding legal matters, such as evictions, landlord/tenant problems, FOIA matters, personnel and employment matters, real estate transactions, grievances, tort and contract actions, civil litigation, policy development or other legal concerns.</li>
<li>Evaluates, processes, and responds to requests made under the Virginia Freedom of Information Act. </li>
<li>Represents RRHA in judicial and non-judicial proceedings arising under the federal Fair Housing Act, the Virginia Fair Housing Law, the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973, and other applicable fair housing laws.</li>
<li>Researches and drafts pleadings, briefs, and other legal documents for litigation and related discovery. Develops arguments and presentations for trials, hearings, appellate hearings, and administrative proceedings.</li>
<li>Represents RRHA in matters related to its low-income public housing (“LIPH”) and property management functions. Coordinates with the General Counsel to develop policies, procedures, and strategies for RRHA to approach LIPH and property management issues. </li>
<li>Renders advice to responsible staff concerning all landlord-tenant laws applicable to RRHA’s business operations, including interpretation of RRHA’s Dwelling Lease and other governing instruments.</li>
<li>Represents RRHA in judicial proceedings arising under RRHA’s LIPH Dwelling Lease, including, without limitation, actions for unlawful detainer and tenant’s assertions. Exercises reasonable discretion to prosecute, defend, dismiss, or settle such claims in accordance with RRHA goals and policies.</li>
<li>Represents RRHA in formal and informal tenant grievance conferences or hearings, as provided in RRHA’s Admissions and Continued Occupancy Policy.</li>
<li>Represents RRHA in other matters as assigned, including, without limitation, public procurement matters, personnel and employment disputes, residential and commercial real estate transactions, corporate law issues, general civil litigation (including personal injury and contract claims), insurance matters, bankruptcy, and construction law.</li>
<li>Manages the formulation and implementation of operational objectives and strategies for the legal department, under the direction of the General Counsel.</li>
<li>Develops working relationships with other RRHA personnel and outside stakeholders to identify needs and establishes processes to resolve issues/problems.</li>
<li>Coordinates use and work of external attorneys. </li>
<li>Develops and implements departmental policies and procedures and ensures compliance with agency policies and procedures. </li>
<li>Drafts and reviews legal documents and proceedings.</li>
<li>As needed, represents the agency as a member of external and internal committees, commissions and task forces, including the public meetings of RRHA’s Board and its Committees.</li>
<li>Formulates legal strategies; initiates, prepares and responds to lawsuits and discovery proceedings; explains matters of law and makes recommendations to clients.</li>
<li>Performs other duties as assigned.</li>
</ul>
Behavioral Competencies 
This position requires the incumbent to exhibit the following behavioral skills:
Job Knowledge:
<ul>
<li>Shares new ideas and perspectives to adjust Authority strategies</li>
<li>Recognizes situations and resources to create desired impact and maximize successful outcomes</li>
<li>Contributes to shaping Authority practices and policies</li>
</ul>
Customer Service:
<ul>
<li>Keeps abreast of the industry and related organizations, proactively identifies, and builds relationships that could lead to future organization opportunities</li>
<li>Maintains knowledge about related organizations and leverages that knowledge to help the Authority</li>
<li>Works with others to understand what matters most to clients and how to respond</li>
</ul>
Effective Communication:
<ul>
<li>Communicates complex issues clearly and credibly with widely varied audiences</li>
<li>Uses communication skills to resolve differences and arrive at the best course of action, when there are conflicting sources of information</li>
<li>Communicates complex technical information in a business context</li>
</ul>
Initiative:
<ul>
<li>Regularly evaluates the effectiveness of team-based improvements using predetermined measures and criteria</li>
<li>Implements new methods, processes, tools, and/or techniques by helping to eliminate internal and external barriers</li>
<li>Creates a work environment conducive to improving programs and services</li>
</ul>
Responsiveness and Accountability:
<ul>
<li>Fosters a sense of urgency, ownership, and personal commitment in and across the department </li>
<li>Is transparent about the department’s goals and provides staff with timely information on progress and outcomes</li>
<li>Creates an environment where honesty, integrity, and personal accountability are rewarded</li>
</ul>
Teamwork:
<ul>
<li>Creates an inclusive work environment by valuing the ideas and opinions of those inside and outside of the team </li>
<li>Proactively shares information about recent decisions and future changes across departments</li>
<li>Creates an environment where others are encouraged and rewarded for working across departments</li>
</ul>
Problem Solving and Analysis:
<ul>
<li>Designs complex problem-solving tools and methods</li>
<li>Identifies the impact of solutions on multiple areas within the organization</li>
<li>Develops contingency measures and explores various problem-solving options</li>
</ul>
Program and Project Management:
<ul>
<li>Oversees the general execution of programs and departmental/organizational projects and balances priorities based on broader Authority goals</li>
<li>Manages risks across multiple projects by examining total resource requirements and assessing impact of projects on the day-to-day operations</li>
<li>Modifies project approach and budget without compromising the quality of outcomes and the desired results</li>
</ul>
Strategic Capability and Leadership
<ul>
<li>Identifies and develops the strategies needed to align the department with organizational goals</li>
<li>Displays and contributes in-depth knowledge to strategic planning at the organizational level</li>
<li>Defines performance measures to evaluate the success of organization’s strategy</li>
</ul>
Job Competencies
<ul>
<li>Comprehensive knowledge of general law and Virginia local government law.</li>
<li>Considerable knowledge of federal, state and city laws and regulations and their relationship to the functions of RRHA.</li>
<li>Considerable knowledge of court operations, including the Rules of the Supreme Court of Virginia.</li>
<li>Considerable knowledge of the principles and practices of administration and supervision.</li>
<li>Ability to organize, interpret, and apply legal principles and knowledge to complex legal problems.</li>
<li>Ability to conduct legal research and to prepare specifications for contracts and other legal documents.</li>
<li>Ability to prepare legal documents, pleadings and motions for cases in litigation.</li>
<li>Ability to conduct investigations of a fact-finding nature, study legal precedents, and prepare recommendations.</li>
<li>Ability to formulate important recommendations or make technical decisions that have both legal and operational impact.</li>
<li>Ability to modulate speaking and writing style to communicate effectively with a range of audiences, including housing assistance recipients, community activists, public and elected officials, and members of the press. </li>
<li>Ability to establish and maintain effective working relationships with associates, other employees, administrative officials, and the public.</li>
</ul>
Education and/or Experience
Education: Juris Doctor degree from a law school accredited by the American Bar Association.
Experience: At least three years’ experience in the practice of law with a preference for experience in landlord-tenant matters, local government law, or general civil litigation. Extensive legal experience working with complex and difficult legal issues and evaluating information in controversial areas. Progressively responsible managerial experience.
ADDITIONAL REQUIREMENTS:
<ul>
<li>Applicant must be lawfully admitted to practice law in the Commonwealth of Virginia and must, during all periods of employment, be an active member in good standing with the Virginia State Bar.</li>
<li>Applicant must be admitted to practice in all courts of the Commonwealth of Virginia. Admission to the U.S. District Court for the Eastern District of Virginia and the U.S. Court of Appeals for the Fourth Circuit preferable but not required.</li>
<li>Applicant must possess and retain a valid motor vehicle operator's license. Note: Applicant must have and maintain a driving record acceptable to RRHA and its insurance carrier(s).</li>
</ul>
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.
To perform this job successfully, the employee is routinely required to remain in a stationary position. Daily movements include sitting; standing; reaching and grasping; operating computers and other office equipment; moving about the office; and attending onsite and offsite meetings. The employee must be able to exchange information in person, in writing, and via telephone. The employee must occasionally transport up to 10 pounds.
There will be times when the Senior Project Manager will have to drive and participate in off-site meetings.
There will be times when the Senior Project Manager will visit and walk vacant property sites and well as drive to construction sites to evaluate the progress on development.
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. 
Office environment. The noise level in the work environment is moderate. 
EEO Statement: RRHA provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal. State or local laws.

Associate Counsel

<h3>Job Description</h3>
Gold Coast Health Plan will not sponsor applicants for work visas.
The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California.
Amount of Travel Required: 10%
Work Culture:
GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive. This philosophy enables us to create the health plan of the future and do our best work – Together.
GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).
GCHP’s focuses on 5 Core Values in the workplace:
• Integrity
• Accountability
• Collaboration
• Trust 
• Respect
Disclaimer: Flexible work schedule is based on job duties, department, organization, or business need.
POSITION SUMMARY
The Gold Coast Health Plan Medical Director will be a physician responsible for providing clinical leadership to the Health Care Services Department, which includes management of the physician processes in support of utilization management, care management, pharmacy and associated transactional functions. These functions include performance of prospective, concurrent, retrospective utilization, member appeal and grievance reviews, and non-UM transactional work including but not limited to facilitating Gold Coast Health Plan’s interdisciplinary care team case conferences, Peer to Peer conference calls with network providers, assisting the Quality Improvement Department implement managed care accountability set (MCAS) initiatives, participating as a member of Gold Coast Health Plan’s UM, and Quality Committees, and providing retrospective provider claims dispute reviews.
The Medical Director is responsible for the day-to-day clinical determinations and transactional operations of Health Care Services. He/She is responsible for the monitoring and oversight of the UM functions performed within Health Care Services the delivery and review of defined metrics to validate business unit/program effectiveness and escalate to Gold Coast Health Plan’s Senior Medical Director the need for appropriate resources available to meet department needs and/or regulatory requirements. He/She is charged with ensuring compliance with requirements for all regulatory and accreditation authorities related to the department’s work and is responsible for ensuring departmental processes are applied and followed by Health Service associates who perform UM and transactional work.
The Gold Coast Health Plan Medical Director works collaboratively with Health Care Services and other appropriate Gold Coast Health Plan departments across product lines to identify and address opportunities to improve clinical quality, member satisfaction, reduce administrative cost and support department and organizational business goals. The Gold Coast Health Plan Medical Director will be responsible for engaging in organization-wide quality improvement efforts and promoting a culture of continuous improvement throughout the organization, and contracted provider partners. 
Reasonable Accommodations Statement
To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.
ESSENTIAL FUNCTIONS
Key Responsibilities
These functions are ongoing and happen simultaneously. The Gold Coast Health Plan Medical Director should be comfortable multi-tasking, prioritizing responsibilities, and adapting to changes.
• Provide clinical and policy expertise for all aspects of physician UM serving as the representative on relevant projects including system implementation, service area and product expansion.
• Work together with the Health Care Service Senior UM Director, Senior Care Management Director, and Director of Pharmacy to monitor UM, CM and Pharmacy processes to identify opportunities for improvement and efficiency.
• Manage team-specific and/or departmental projects, as assigned by Gold Coast Health Plan Chief Medical Officer or the Gold Coast Health Plan Senior Medical Director.
• Escalate to Senior Medical Director, regulatory or public facing risks including root cause analysis and any corrective actions.
• Monitor quality, and reduction of targeted population health care inequities through the interpretation of UM, CM, and/or Pharmacy data and metrics.
• Together with the Health Services Senior UM Director, Senior CM Director, and Pharmacy Director review, revise and monitor policies and procedures to ensure that all work of the department meets all regulatory and accrediting standards for all products.
• Ensure all regulatory, operational and documentation standards and reporting needs are met.
• Manage day-to-day integration of technology to support department transactional functions.
• Establish and reinforce processes for implementing various inputs of information to support all lines of business including assessing and implementing new technology.
• Continuously work to identify and implement administrative efficiencies within the department.
• Serve as a clinical resource to both non-clinical and clinical Gold Coast Health Plan staff.
• Other duties as assigned.
Transactional Work
• Perform clinical review of prospective, concurrent, and retrospective coverage requests; and standard and expedited member appeals/grievances for in-patient and outpatient services requiring prior authorization and concurrent review.
• Provide physician support and leadership for the care management rounds and care planning activities for all lines of business as required.
• Participate in the Gold Coast Health Plan inter-rater reliability program.
• Perform provider claims dispute reviews.
• Provide physician expertise for the development/modification of claims payment rules.
• Participate in training of Gold Coast Health Plan Health Care Services staff.
• Participate in or lead relevant committee and staff meetings producing appropriate documentation and carrying out follow-up as needed to ensure business objectives are met.
• Serve as internal consultant/clinical resource to other departments as needed.
• Represent Gold Coast Health Plan in relevant external meetings and initiatives as assigned by the Gold Coast Health Plan Senior Medical Director and/or Gold Coast Health Plan Chief Medical Officer.
Staff Development
Create a team succession plan that provides opportunities for growth and ensures business process continuity.
• Be a resource to Gold Coast Health Plan and the Health Services Department for complex situations.
Quality
Work with Quality teams to improve quality scores (HEDIS and STARS)
• Meet regularly with the Quality Improvement team to review and adjust tactics to improve quality measurement performance.
• Participate in scheduled joint quality, and operations meetings with network provider groups quality measure progress, and collaborate with network providers to develop strategies and tactics for improved quality measurement performance.
• Review, analyze, and draft responses to member and provider grievances.
• Engage contracted providers with high frequency of member grievances.
Pharmacy
• Collaborate with the Gold Coast Health Plan Pharmacy department to provide clinical review of authorization requests. 
MINIMUM QUALIFICATIONS
Education &amp; Experience: Please identify the nature of education and experience such as: Associates, Bachelor’s and/or Master’s degree (four-year college or technical school) and list any applicable specialty or field of study.
• Doctorate Degree in Medicine.
• Board Certification in a medical specialty.
• Minimum 5 years previous Medical Director or equivalent medical leadership role.
• Minimum 5 years Utilization/Quality Program Management experience.
• Minimum 5 years clinical practice.
• Minimum 5 years HMO/Managed Care experience. 
Preferred Experience:
• Peer Review, credentialing, quality improvement, medical policy/procedure development, provider contracting experience. 
Equivalent In lieu of degree: 
• Not applicable
KNOWLEDGE, SKILLS &amp; ABILITIES
Preferred Qualifications: 
• Working knowledge of population health management and/or health care inequities 
• Masters Public Health Degree
Technology &amp; Software Skills: Advanced computer skills in MS Office products.
Certifications &amp; Licenses: A valid and current Driver's License, Auto Insurance, and professional licensure(s)
Competency Statements 
• Management Skills - Ability to organize and direct oneself and effectively supervise others.
• Business Acumen - Ability to grasp and understand business concepts and issues.
• Decision Making - Ability to make critical decisions while following company procedures.
• Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.
• Interpersonal - Ability to get along well with a variety of personalities and individuals.
• Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.
• Time Management - Ability to utilize the available time to organize and complete work within given deadlines.
• Consensus Building - Ability to bring about group solidarity to achieve a goal.
• Relationship Building - Ability to effectively build relationships with customers and co-workers.
• Presentation Skills - Ability to effectively present information publicly.
• Delegating Responsibility - Ability to allocate authority and/or task responsibility to appropriate people.
• Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions.
• Strategic Planning - Ability to develop a vision for the future and create a culture in which the long-range goals can be achieved.
• Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.
• Judgment - The ability to formulate a sound decision using the available information.
• Communication, Oral - Ability to communicate effectively with others using the spoken word. 
• Communication, Written - Ability to communicate in writing clearly and concisely. 
• Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.

Medical Director

<h3>Job Description</h3>
Full Job Description
Job Type: Full-time
Pay Range: $23.00 – $25.00 per hour
Job purpose ***This is an in-office position***
The Member Services Representative is responsible for assisting Members, Providers, and Health Plan staff by providing accurate answers to questions regarding the Health Plan in a timely and courteous manner. The Member Care Professional may also facilitate the process for Health-Education related activities and other Health Plan functions and events.
Duties and responsibilities
<ul>
<li>Answers Member/Provider telephone inquiries via ACD phone system.</li>
<li>Always maintains professional and courteous telephone etiquette, based on Sonder’s core values.</li>
<li>Logs all calls in Salesforce (CRM platform).</li>
<li>Provides status on claims, prior authorizations, and eligibility to Members and Providers.</li>
<li>Facilitate phone conversations with the Member and/or Provider.</li>
<li>Assist Members with but not limited to (benefits, PCP lookup, appointment setting, scheduling transportation, and documenting Grievance and/or appeals).</li>
<li>Follow up on resolution of inquiries and communicating to all parties involved, in a timely and professional manner.</li>
<li>Attends Customer Service &amp; staff training, as required.</li>
<li>Assists and supports other Member Services Department staff, as needed.</li>
<li>Maintains and keeps in total confidentiality, all files, documents, and records that pertain to the operation of business of the Health Plan.</li>
<li>All other job-related duties as it relates to the job function or as delegated by the management team.</li>
</ul>
Education/ Experience/Qualifications
Required
<ul>
<li>Three-five years minimum Member/Provider service experience in a healthcare environment.</li>
<li>Excellent verbal and written communication skills.</li>
<li>Excellent organization skills with ability to handle multiple tasks and prioritize work in a fast-paced environment.</li>
<li>Three – five-year minimum ACD or comparable multi-line call center experience.</li>
<li>Computer literate with high proficiency in Microsoft applications.</li>
</ul>
Preferred
<ul>
<li>The knowledge, skills and abilities typically acquired through the completion of an associate’s degree.</li>
<li>Extensive Medicare experience.</li>
<li>Familiar with start-up companies.</li>
<li>Familiar with CMS regulations.</li>
<li>Bilingual (English/Spanish).</li>
</ul>
Job Type: Full-time
Pay: $23.00 – $25.00 per hour
Benefits:
<ul>
<li>401(k)</li>
<li>Dental insurance</li>
<li>Health insurance</li>
<li>Paid time off</li>
<li>Vision insurance</li>
</ul>
Schedule:
<ul>
<li>8 hour shift</li>
<li>Monday to Friday</li>
<li>Weekend availability</li>
</ul>
Work Location: One location
Ability to commute/relocate:
<ul>
<li>Atlanta, GA 30339: Reliably commute or planning to relocate before starting work (Required)</li>
</ul>
Application Question(s):
<ul>
<li>Do you have Medicare Advantage insurance experience?</li>
</ul>
Experience:
<ul>
<li>Claims: 1 year (Preferred)</li>
<li>Medicare Advantage: 1 year (Preferred)</li>
</ul>

Members Services Representative

<h3>Job Description</h3>
Full Job Description
Job Type: Part-time
Pay: $21.00 per hour
Job purpose ***This is an in-office position***
The Member Services Representative is responsible for assisting Members, Providers, and Health Plan staff by providing accurate answers to questions regarding the Health Plan in a timely and courteous manner. The Member Care Professional may also facilitate the process for Health-Education related activities and other Health Plan functions and events.
Duties and responsibilities
<ul>
<li>Answers Member/Provider telephone inquiries via ACD phone system.</li>
<li>Always maintains professional and courteous telephone etiquette, based on Sonder’s core values.</li>
<li>Logs all calls in Salesforce (CRM platform).</li>
<li>Provides status on claims, prior authorizations, and eligibility to Members and Providers.</li>
<li>Facilitate phone conversations with the Member and/or Provider.</li>
<li>Assist Members with but not limited to (benefits, PCP lookup, appointment setting, scheduling transportation, and documenting Grievance and/or appeals).</li>
<li>Follow up on resolution of inquiries and communicating to all parties involved, in a timely and professional manner.</li>
<li>Attends Customer Service &amp; staff training, as required.</li>
<li>Assists and supports other Member Services Department staff, as needed.</li>
<li>Maintains and keeps in total confidentiality, all files, documents, and records that pertain to the operation of business of the Health Plan.</li>
<li>All other job-related duties as it relates to the job function or as delegated by the management team.</li>
</ul>
Education/ Experience/Qualifications
Required
<ul>
<li>Three-five years minimum Member/Provider service experience in a healthcare environment.</li>
<li>Excellent verbal and written communication skills.</li>
<li>Excellent organization skills with ability to handle multiple tasks and prioritize work in a fast-paced environment.</li>
<li>Three – five-year minimum ACD or comparable multi-line call center experience.</li>
<li>Computer literate with high proficiency in Microsoft applications.</li>
</ul>
Preferred
<ul>
<li>The knowledge, skills and abilities typically acquired through the completion of an associate’s degree.</li>
<li>Extensive Medicare experience.</li>
<li>Familiar with start-up companies.</li>
<li>Familiar with CMS regulations.</li>
<li>Bilingual (English/Spanish).</li>
</ul>
Job Type: Part-time
Pay: $21.00 per hour
Schedule:
<ul>
<li>Various shifts</li>
<li>Monday to Friday</li>
<li>Weekend availability</li>
</ul>
Work Location: One location
Ability to commute/relocate:
<ul>
<li>Atlanta, GA 30339: Reliably commute or planning to relocate before starting work (Required)</li>
</ul>
Application Question(s):
<ul>
<li>Do you have Medicare Advantage insurance experience?</li>
</ul>
Experience:
<ul>
<li>Claims: 1 year (Preferred)</li>
<li>Medicare Advantage: 1 year (Preferred)</li>
</ul>

Member Services Representative - P/T

<h3>Job Description</h3>
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.

**Position is FULLY ONSITE Mon-Friday, Bilingual in Spanish is required**
Location: 9250 NW 36th St, Miami, FL 33178
Solis offers competitive benefits including:
<ul>
<li>Paid Time Off</li>
<li>Paid Holidays</li>
<li>Paid Long Term Disability &amp; Life Insurance policy</li>
<li>401k Matching Program</li>
<li>Health, Vision &amp; Dental Insurance </li>
<li>Critical Illness, Hospital and Accident Insurance</li>
<li>Legal &amp; Transit benefits</li>
<li>Employee Appreciation Events</li>
<li>Positive &amp; Supportive Work Environment</li>
</ul>
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>During AEP, October 1 through March 31st they are required to be a part of the weekend rotation.</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>
This work requires the following physical activities: climbing, bending, stooping, kneeling, twisting, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lift, and moves intermittently during working hours. Work schedule is approximate and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including on weekends and holidays as needed.
Qualification and Education
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.
<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

<h3>Job Description</h3>
Job Summary
Recipient Rights Specialists act as regulatory officers enforcing the Michigan Mental Health Code (MHC), Administrative Rules, OCHN policies and procedures, and Public Acts as mandated under state law. Recipient Rights Specialists act as advocates to inform individuals receiving behavioral health services of their rights and assist them in problem-solving within the Rights &amp; Advocacy unit. This may entail working cooperatively with, but not limited to, Customer Services, Due Process, or other units within OCHN.
Essential Function:
<ul>
<li>Collect and analyze information and make decisions. Act as the point of collection for all information relevant to recipient rights and alleged rights violations.</li>
<li>Conduct rights investigations. Analyze evidence to determine whether a violation of code-protected right has occurred; interview individuals receiving services, guardians, contracted/sub-contracted staff, and other witnesses; secure records; obtain and analyze evidence. Make referrals to other community and regulatory agencies.</li>
<li>Generate required reports from investigations, including decisions and recommendations for remedial/disciplinary action of substantiated violations; review action for MHC, Administrative Rules, OCHN policy/procedures, and contract compliance; make referrals to the Service Network Team for contract actions; serve as a consultant to the Administration in matters relevant to rights; provide crisis recommendations as needed; and participate as required in the Grievance and Appeals and Mediation process. </li>
<li>Maintain all required timelines for Recipient Rights-related documentation, including reports, letters, and other documents.</li>
<li>Provide technical assistance related to Recipient Rights to contract providers and the public. </li>
<li>Analyze and track patterns relating to rights issues within their territory.</li>
<li>Maintain data on all substantiated perpetrators and recipient demographic information; provide information to maintain database with recipients, sites, core and network provider information.</li>
<li>Coordinate and ensure the organization’s effort to fulfill requirements for the MDHHS and MDHHS-ORR audits, participate in provider monitoring efforts as a member of the Recipient Rights Team, Quality Improvement and Regulatory Compliance Team or other auditing or monitoring process assigned by the ORR Manager.</li>
<li>Review and analyze all incident reports relevant to assigned territory. Code using appropriate ORR/OCHN IR Code in a timely manner. Open complaint and begin investigative process as deemed appropriate based on IR content. </li>
<li>Obtain, review, and analyze information involving recipient deaths; coordinate information collection from the County Clerk and Medical Examiner’s office; review autopsy reports, death certificates, and mortality reports; ascertain if a death warrants a rights investigation; input death information into database; provide data to the Sentinel Event Review Committee (SERC) or other OCHN Team or Office as necessary; and consult with SERC as needed or other OCHN Team or Office as necessary. </li>
<li>Assist the training unit with the provision of recipient rights training as needed and qualified.</li>
<li>Serve as a source of consultation and education for the OCHN provider network regarding Rights related issues.</li>
<li>Maintain a positive and professional relationship with individuals receiving services and providers operating within the assigned territory. Conduct friendly visits during times when there are no investigations to build rapport.</li>
<li>Assume duties as assigned that support ORR and OCHN operations. These can include being a liaison with Adult Protective Services, helping with licensing verifications, sitting on one or more OCHN communities as the Rights representative, assisting with New Hire training, and others.</li>
</ul>
Education: 
A bachelor’s degree from an accredited college or university in a relevant discipline is required. 
Experience Requirements:

<ul>
<li>At least one year of work experience in administrative, rights advisor, support coordinator, case manager capacity, or related position. </li>
<li>Experience with and demonstrated understanding of behavioral health services. </li>
<li>Understanding of the Oakland County/OCHN public behavioral health system is preferred. </li>
<li>Investigative experience is preferred and highly beneficial. </li>
<li>Effective communication skills, including verbal and written communication.</li>
<li>Excellence in writing skills and report writing.</li>
</ul>
Preferred Requirements:
<ul>
<li>Experience with interviewing, such as forensic or motivational interviewing.</li>
<li>Experience with technical writing.</li>
<li>Experience working with a variety of populations, including people with intellectual disabilities, individuals with mental illness, and others.</li>
</ul>
Job Specific Competencies/Skills:
<ul>
<li>Must make sound judgments and conclusions. </li>
<li>Interface professionally with individuals receiving services, secondary consumers, contracted/sub-contracted employees, and the public. </li>
<li>Must have excellent time management skills. </li>
<li>Must be able to work with multiple timelines to achieve statutory compliance. </li>
<li>Must possess excellent report writing and verbal skills. </li>
<li>Must be able to travel county-wide and statewide as needed. </li>
</ul>
Oakland Community Health Network’s Core Competencies:
<ul>
<li>Interacting with others in a way that gives them confidence in one’s intentions and those of the organization; demonstrating loyalty to the organization and its mission and values; maintaining social, ethical, and organizational norms; firmly adhering to codes of conduct and ethical principles. (Integrity/Building Trust)</li>
<li>Making customers and their needs a primary focus of one’s actions; developing and sustaining productive customer relationships, recognizing that the ultimate customer is the person served. (Customer Focus)</li>
<li>Actively identifying new areas for learning; regularly creating and taking advantage of learning opportunities; using newly gained knowledge and skill on the job and learning through their application. (Continuous Learning) </li>
<li>Setting high standards of performance for self and others; assuming responsibility and accountability for successfully completing assignments or tasks; self-imposing standards of excellence in addition to consciously adopting organizational standards of excellence. (Work Standards)</li>
<li>Clearly conveying information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message. (Communication)</li>
</ul>
(Travel required, physical requirements, on-call schedules, etc.): 
<ul>
<li>Must have available means of transportation to and from OCHN and for required offsite meetings or site visits.</li>
<li>Must be available for meetings and events which may occur outside of standard office hours.</li>
<li>Work performed primarily in the community with remote work from home.</li>
<li>The ideal candidate must be able to complete all physical requirements of the job with or without a reasonable accommodation.</li>
</ul>
OCHN is committed to building a diverse team and fostering an inclusive and equitable culture. We are proud to be an equal opportunity employer that embraces and encourages our employees’

Recipient Rights Specialist

<h3>Job Description</h3>
Member Services Specialist
South Country Health Alliance located in Medford, MN, has an immediate opening for a full- time Member Services Specialist at our Medford location.
The Member Services Specialist serves as the primary point of contact in our call center. The Member Services Specialist assists members telephonically with issues involving enrollment, transportation, benefit questions, coverage limits, payments, claims, and those matters that involve provider networks.
The position hours are from 8 a.m. - 4:30 p.m. M-F, with flexibility to work additional hours, including limited weekends during open enrollment (October thru March) and holidays.
Requirements include a High school diploma or equivalent. At least one year of practical experience in customer service or call center is also required. Preferred: Bilingual; Post high school education in business; Healthcare or insurance experience; Knowledge of Medicaid and Medicare rules.
South Country offers a full range of comprehensive benefits and competitive pay. View full position description below and text MSS to 507-565-6775 to apply!
This position is a grade 3 and starts at $18.50/hour
POSITION DESCRIPTION (Non-Exempt)
Position Title: Member Services Specialist
Dept.: Operations Department
Reports To: Member Services Manager
Date: March 2024
Skill Set: Computer savvy and proficient in the use of Microsoft Office Suite and Chrome in order to navigate and retrieve information from a variety of software and internet applications, including numerous third party administrator (TPA) systems; Self-directed, highly organized and very detail oriented in completing multiple assigned tasks simultaneously; Conversational with a variety of personality styles; High level of patience to work with a diverse caller group; Good written communication skills to document calls in a clear and concise manner; Excellent verbal communication skills and enjoy working with the public via telephone for extended periods of time; Adaptable to a continually changing environment and able to maintain a high degree of confidentiality.
Education/Experience: Required: High school diploma or equivalent. At least one year of practical experience in customer service or call center required. Preferred: Bilingual; Post high school education in business; Healthcare or insurance experience; Knowledge of Medicaid and Medicare rules.
Basic Function As the primary point of contact in our Call Center, the Member Services Specialist provides accurate information and assistance to members involving enrollment, transportation, benefit questions, coverage limits, payments, claims, and those matters that involve provider networks. This may be over the phone or in person.
Essential Job Duties 1. Provides assistance to members with questions, concerns, and complaints they may have regarding their enrollment, benefits, and/or services provided by South Country in a professional and efficient manner that allows members to receive exceptional service and accurate information.
2. Participate in the day-to-day RideConnect program to effectively schedule member transportation requests. This may include intaking requests, verification of appointments, identification of the most cost-effective provider, outreach to providers to check availability, book rides, confirm rides with members, coordinate ride modifications, ride cancellations, and other tasks necessary to coordinate transportation.
3. Utilize and navigate multiple computer systems, including a cloud-based phone system, to provide service to our members. Procedures and workflows are followed accurately and completely.
4. All interactions are documented (calls, emails, and face to face conversations) in a CRM software to ensure that any audit, follow-up communication, grievance or appeal can be handled in an accurate, appropriate, and timely manner.
5. Assist Community Care Connectors (CCC) and other county staff with benefit questions, location of network providers, pharmacy issues, member materials, etc. in order that members are provided the best continuum of care possible.
6. Be aware of, or be able to obtain, Federal, State, and County laws and rules that regulate the provision of health care services to South Country members, including those that apply to enrollee Grievances and Appeals, in order that South Country and its employees are in compliance with such laws and rules and that members suffer no loss of coverage.
7. Determine when an issue needs to be escalated to supervisor or other management personnel.
8. Perform other duties as assigned within the scope, responsibility, and requirements of the job.
Qualification Requirements:
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.
Language Skills:
Must be able to read and write in English. Knowledge of Spanish and/or Somali languages a plus. Ability to access interpretation services, if needed.
Mathematical Skills:
Basic mathematical skills required.
Accuracy:
It is critical for the Member Services Specialist to communicate accurate information to enrollees regarding their healthcare benefits. The impact of errors or negligence in communicating incorrect information/benefits could be significant. In these instances, members could miss or be late for their medical appointments, and South Country could incur costs of paying claims for inaccurate services not in the member’s benefit set. Quality checks may identify these errors, but this would be during a retro review.
Reasoning Ability:
Must be able to draw conclusions from past practice, essential information, rules and regulations, and common sense. Requires the use of judgment to research and make decisions in communicating benefits. Problem solving may be of a more challenging degree.
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 talk or listen. The employee frequently is required to sit for lengthy periods of time. The employee is occasionally required to stand, walk; use hands to finger, handle, or feel objects, tools, or controls; and reach with hands and arms.
The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and the ability to adjust focus.
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.
While performing the duties of this job, the employee should encounter no unusual or hazardous conditions. The noise level in the work environment does vary depending on call volume and number of member services staff on duty.
Travel Requirements:
This position has limited exposure to out-of-town travel but may be required to occasionally travel.
Contacts:
The Member Services Specialist obtains specific cooperation from personnel regarding work received from another or work delivered to another. This position has constant contact with enrollees, both via telephone and face-to-face, and works closely with the community care connectors, specific internal staff, as well as several TPAs and has occasional contact with providers.
The Member Services Specialist will communicate with members in a professional, courteous manner that will build trust, enabling the enrollee to have full confidence that they are receiving the correct information regarding their benefits. Based upon their experience assisting enrollees in solving benefit issues or concerns, this position will help to develop policies and procedures that can be used as guidelines when similar situations arise in the future.
Financial Impact:
Errors in communicating benefits to members could negatively impact South Country at a moderate to significant level depending on the individual situation. If a Member Services Specialist indicates to a member that a service is covered, but it really is not, South Country could incur the costs of paying those claims.

9 grievance-and-appeals-representative Jobs