A great job awaits! http://caresource.isg2.com/menu.asp?sst=isg-lightblue en-us Fri, 30 Jul 2010 15:19:22 GMT © 2010 HR Services, Inc. Job Summary: Customer Service Representative I will assist Medicaid and Medicare members/providers with benefit, claims, and other inquiries. The CSR I provides quality service by immediately responding to the member and/or providers requests and complaints, and appropriately routing issues to the correct department for timely resolution. CSR’s are also required to capture member grievance, and relay appeals instructions for the appropriate line of business, including future lines of business. Essential Functions: • Assist members with routine servicing inquires including but not limited to; selecting a primary care physician, member benefit education, member identification cards, transportation arrangements, issues with provider accessibility, eligibility inquires, resolving member complaints, identifying and filing member grievances. • Assist a provider with routine servicing inquires including but not limited to; verifying eligibility, explanation of benefits, claims and appeal procedures. • Ensuring all HIPAA and State requirements/regulations are adhered too at all times, in existing and future lines of business. • Research, follow up, and resolve all open/pending issues in a timely manner to ensure member satisfaction. • Build and strengthen member relationships by providing quality customer service. • Maintain knowledge and understanding of all processes and procedures. • Adhere to all departmental and company policies and procedures. • Maintain complete and accurate documentation of all of telephone and written communications. • Act as a mentor to new hire employees. • Screen members to determine Case Management needs, and refer when appropriate. • Appropriately route calls to support departments including Pharmacy, and Triage, for proper/expedited resolution. • Assist with non phone work such as incoming faxes and web inquires. https://www.appone.com/MainInfoReq.asp?R_ID=486051&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=486051&B_ID=20&fid=1 Thu, 29 Jul 2010 00:00:00 GMT Job Summary: Responsible for the coordination, development and maintenance of the Service Operations knowledge repository that houses policies, procedures, process flows, and job aides for service representatives to utilize in response to member and provider call inquiries for Medicaid, Medicare, and future lines of business. Responsible for training and communications to Service Operations staff on new and revised policies, procedures, job aides, and processes flow information within the knowledge repository as changes occur. Essential Functions: • Identify, develop and design information for the knowledge repository for Service Operations functions including Grievance, Appeals, Provider and Member Services. • Collaborate with other departments to develop and/or review cross-functional policies, procedures, process flows, and job aids. • Collaborate with Service Operation’s and Internal Auditing teams on a regular basis to identify new or changing processes. • Attend departmental and project meetings to identify additional policy, procedural, process flow, and job aid information needs. • Job shadow with Service Center Representatives to identify additional policy and procedure needs. • Design and maintain master list of policies, procedures and owners on Share Point. • Develop and communicate the process of updating the policies and procedures when departmental changes occur. • Identify, review and communicate annual policy and procedure updates to appropriate staff and ensure completeness. • Educate employees on changes to the knowledge repository including new and/or revised policies, procedures, process flow, and job aids on an ongoing basis through arranged sessions, staff meetings, new hire training, one on one sessions, Share Point updates and e-mail. • Provide management with opportunities for improvement related to policy, procedural and training functions. • Perform any other job related instructions as requested, with reasonable accommodation https://www.appone.com/MainInfoReq.asp?R_ID=487004&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=487004&B_ID=20&fid=1 Thu, 29 Jul 2010 00:00:00 GMT Job Summary: Provide leadership and direction to the Claim Processing teams to ensure the goals and standards of the department and CareSource are being met. Development of cross-functional work teams within the Claims Department. Participate in ongoing development of new products and technologies. Manage projects and inventory aging through effective allocation of resources. Essential Functions: • Guide team leads and analysts relative to daily operational functions. • Ensure quantitative and qualitative measures are used to meet performance objectives. • Manage staffing and scheduling functions. • Engage direct reports through consistent performance feedback and development opportunities. • Compile reports and departmental communications. • Participate in strategic planning and implement action plans. • Interface with team leads on effective people management strategies such as staffing, coaching and mentoring. • Lead/participate in strategic department/company projects. • Identify and facilitate process improvements to improve productivity, accuracy, and data usability. • Maintain positive relationship with internal and external customers. • Perform any other job related duties as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=488831&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=488831&B_ID=20&fid=1 Thu, 29 Jul 2010 00:00:00 GMT Job Summary: Coordinate the care, services and health benefits for selected member populations across the continuum of illness. Monitor and promote effect utilization of healthcare resources through clinical variance and benefits management. Essential Functions: • Develop and implement care plan, defining specific issues, goals and interventions as agreed to by all parties. • Monitor and evaluate care plan on an ongoing basis through member, family and treatment team contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician. • Assist in education of members regarding healthcare access and benefits, and provide members with health education and wellness materials. • Participate in meetings with providers to inform them of Case Management services and benefits available to members. • Complete assessments by gathering information from the member, family and treatment team. • Arrange and coordinate services with other healthcare disciplines while maximizing utilization of appropriate community resources and support groups. • Verify eligibility, previous enrollment history, demographics and current health status of each member. • Maintain current and accurate documentation of telephonic contacts, treatment plans, case notes, referrals, and assessments in Case Management electronic record. • Maintain appropriate documentation within protocols and guidelines of the Case Management program. • Perform any other job related instructions as requested, with reasonable accommodation. • Precepting and or mentoring new staff https://www.appone.com/MainInfoReq.asp?R_ID=486530&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=486530&B_ID=20&fid=1 Mon, 26 Jul 2010 00:00:00 GMT Develop new programs, systems and/or computing infrastructure. Identify and document business requirements for new development projects and prepare detailed technical specifications from which programs or infrastructure can be built. Provide day-to-day support and monitoring of the computing systems environment. Assist in hardware/software changes to computing systems environment. https://www.appone.com/MainInfoReq.asp?R_ID=488329&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=488329&B_ID=20&fid=1 Mon, 26 Jul 2010 00:00:00 GMT Job Summary: Responsible for the completion of clinical appeals and state hearings from all states. Collaborate with the Quality Improvement, Clinical Operations Team Lead to prepare all requests for Independent External Review. Complete all responsibilities ensuring compliance with all Federal, State, and Accreditation requirements. Essential Functions: • Review and complete all provider clinical appeals within required timeframes • Review and complete member clinical appeals within required timeframes • Review all information necessary to prepare State Hearing packets • Communicate with state agencies and internal departments to prepare for State Hearings • Attend assigned State Hearings and complete all required compliances. • Complete required compliances for Administrative Hearing decisions. • Apply CareSource Medical Policy and Milliman guidelines when processing clinical appeals • Issue notification letters to providers and members • Issue administrative denials appropriately • Refer denials based on medical necessity to medical director • Maintain hardcopy documentation, Facets documentation and appeals database documentation at 90-95% accuracy rates • Conduct monthly, quarterly and ad hoc appeals reporting • Collaborate with the Quality Improvement, Clinical Operations Team Lead to prepare all requests for Independent External Review • Ensure compliance with regulatory and accrediting requirement • Perform any other job related instructions as requested, with reasonable accommodation https://www.appone.com/MainInfoReq.asp?R_ID=487479&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=487479&B_ID=20&fid=1 Thu, 22 Jul 2010 00:00:00 GMT Job Summary: Senior-most source of technical expertise in I.T. Operations (Automation Center of Unified Operations Center). Oversees, develops and implements procedural improvement, work simplification, improvement of manual processes from inception to completion. Assignments are comprehensive and complex and entail interactions between departmental elements and may involve other areas of the organization at various levels of management. Determines, documents and edits Operations procedures and documentation. Develops and tests Operations performance metrics and produces when needed. Trains other team members, including Operations Specialists. Performs daily Operations tasks if necessary. Essential Functions: 1. Provides support and expertise for Operations job automation and scheduling • Automates Operations tasks using Tidal, Power Shell, Batch, Windows Script Host, etc. • Configures Tidal job scheduler to run and track jobs • Automates at least the following IT Operational tasks: o FTP o Application Administration Task o Active Directory Administration Task o Application and System Maintenance o File (Archiving, Moving, Verifying and Editing) o Backup systems and file o EDI file processing 2. Analyzes Operations tasks and functions and identifies opportunities or methods to automate or otherwise improve processes • Identifies and breaks down tasks into components steps • Analyzes Jobs and Job schedule for improvements in quality and performance • Leads and produces deliverables in task automation projects • Determines best tools for automation goals • Defines procedures and standards to be used in achieving automation goals 3. Primary point of contact for Operations putting program changes, enhancements, etc. into IT Production processing • Understands and relates business functional requirements to Operations requirements 4. Defines, documents, and implements Operations procedures 5. Defines and produces Operations performance metrics 6. Provides technical guidance, training, and work direction to Operations team members and Operations Specialists • Demonstrates technical proficiency in automation, automation tools, and the production environment through ability to guide others • Strong learning competency and ability to teach others • Advanced troubleshooting and problem solving capabilities • Mentors and trains Operators and Operations Specialists 7. Provides day-to-day Administration, Support and Monitoring of the computing systems environment • Monitors online systems, files, batch processing, and infrastructure to ensure successful processing • Assists in performance tuning as requested • Performs Active directory user and systems Administration • Performs application User and systems administration • Accurately notifies all applicable constituents of incidents or problem occurrences with daily processing including customers using the systems, IT staff supporting the systems, vend https://www.appone.com/MainInfoReq.asp?R_ID=487509&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=487509&B_ID=20&fid=1 Wed, 21 Jul 2010 00:00:00 GMT Job Summary: This position will manage all aspects of the Health Care Home (HCH) Program. This position will manage all CareSource staff assigned to the Health Care Home Program. This position is responsible for developing and sustaining internal and external relationships with key stakeholders to ensure successful implementation and maintenance of this program. This position will work with DSI and other departments to develop metrics and reports for provider participants and will conduct face-to-face or telephonic meetings with the participants to optimize the relationship and share relevant data to ensure successful outcomes. This position will represent CareSource in the community and with state and local community agencies as appropriate. Developing a positive relationship with key stakeholders represents an opportunity to collaborate on shared issues as well as an opportunity to facilitate better communication and processes to ensure seamless delivery of services to our members optimizing the use of community agencies. This position will be the subject matter expert on practice transformation and will educate internal and external stakeholders on this topic. Manage CareSource Health Care Home Care Management activities and initiatives in collaboration with CareSource departments and community and state agencies to ensure effectiveness of CareSource Health Care Home Program. Essential Functions: • Manage all aspects of the Health Care Home Program. • Manage/supervise all Health Care Home staff. • Serve as a liaison with providers, community agencies, and internal CS staff to facilitate collaboration, process improvement and education so that they are well informed of CareSource benefits, regulatory requirements, current clinical practice guidelines and processes. • Work on development and implementation of processes and procedures to provide management of the Health Care Home Program. • Work with the Care Management management team to ensure adequate staff assignment to the HCH participants. • Develop communications related to the Health Care Home Program on issues, benefits and services (via direct letters, articles in our Provider Newsletter, and on the web). Collaborate with Care Management staff, Provider Relations and Marketing to devise strategies that will keep providers up to date on services, provided feedback on performance and receive feedback from them on ways to improve our services. • Work with CareSource Care Management staff to share information received from local agencies that will improve coordination of care with local agencies and provider participants. • Collaborate with internal CareSource Departments, and provider participants to facilitate communication on state and local agencies on shared initiatives. • Conduct presentations to external providers about internal Care Management activities to foster collaboration regarding care management services within the community. • Perform https://www.appone.com/MainInfoReq.asp?R_ID=486618&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=486618&B_ID=20&fid=1 Wed, 21 Jul 2010 00:00:00 GMT Job Summary: Coordinate the care, services and health benefits for selected member populations across the continuum of illness. Monitor and promote effect utilization of healthcare resources through clinical variance and benefits management. Essential Functions: • Develop and implement care plan, defining specific issues, goals and interventions as agreed to by all parties. • Monitor and evaluate care plan on an ongoing basis through member, family and treatment team contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician. • Assist in education of members regarding healthcare access and benefits, and provide members with health education and wellness materials. • Participate in meetings with providers to inform them of Case Management services and benefits available to members. • Complete assessments by gathering information from the member, family and treatment team. • Arrange and coordinate services with other healthcare disciplines while maximizing utilization of appropriate community resources and support groups. • Verify eligibility, previous enrollment history, demographics and current health status of each member. • Maintain current and accurate documentation of telephonic contacts, treatment plans, case notes, referrals, and assessments in Case Management electronic record. • Maintain appropriate documentation within protocols and guidelines of the Case Management program. • Perform any other job related instructions as requested, with reasonable accommodation. • Precepting and or mentoring new staff https://www.appone.com/MainInfoReq.asp?R_ID=486636&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=486636&B_ID=20&fid=1 Wed, 21 Jul 2010 00:00:00 GMT Job Summary: The Outreach Specialist is responsible for initiating outreach contact with all new members, identifying members who would benefit from case management or disease management services, and maintaining a caseload consisting of members identified with Case/Disease Management diagnosis. The Outreach Specialist must communicate appropriately and effectively with members from diverse cultures. Essential Functions: Employees in this position verify eligibility, previous enrollment history, demographics, and current health status of each member. They maintain accurate documentation of telephone contacts and actions to meet state and federal reporting requirements and to comply with quality assurance standards. They use multiple internal systems including systems for claims, case management and the telephone. Functions include: 1. Welcome Calls • Make initial contact with all new members within the first month of enrollment to welcome them to the plan, convey benefit information and perform initial health risk assessment. • Explain basic managed care concepts, plan benefits and options for appropriate access to care. • Establish positive communications with members via telephonic contact. • Refer and assist members in accessing needed community services within the scope of the Outreach Specialist’s training and serve as a resource for provider offices needing assistance with resource utilization. 2. Health Risk Assessment • Perform data entry of the Health Risk Assessment Tools (HRATs) received in the office. • Appropriately solicit detailed health information from member(s) through telephonic interviewing. • Based on health risk assessment, transfer qualified members to the Nurse Queue for completion of Baseline Assessment 3. Outreach • Initiate outreach contact with members identified from reports. • Initiate outreach contact from member service referrals, medical management referrals, Triage referrals. • Responsible for the explaining Case/Disease Management and benefits provided to the member. 4. Case Load • Collect information and make appropriate contacts with the member’s parents/guardian Maintain members on the case load until member is enrolled within their specified program such as ABD or CSHN, or, member opts out of the program. • Retrieve referrals from Customer Service and make appropriate contacts with the members/guardian. 5. Educational Mailings • Mail educational materials per routing request for Disease Management or Case Management 6. Monthly reporting / case load activities • Report monthly statistics for case management for the Key Statistics report • Create case closure report for audits • Import Pharmacy report into the database and schedule mailings • Verify eligibility on all open cases monthly • Enter health risk assessments received into the database and schedule mailings. 7. Other Functions • Create and submit reports to Manager as requested. Maintain accurate documentation https://www.appone.com/MainInfoReq.asp?R_ID=486654&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=486654&B_ID=20&fid=1 Wed, 21 Jul 2010 00:00:00 GMT Job Summary: Provide support, direction and assistance to CM staff. Give effective and timely feedback to staff in regards to performance outcomes and progress toward goals. Assist with integration of CM and Outreach services to meet departmental goals and objectives. Essential Functions: • Monitor work allocation to maximize output and effectiveness of staff. • Provide daily oversight of scheduling and attendance of personnel. • Monitor performance of staff members through ongoing audit process. • Provide ongoing training, mentoring, coaching and disciplinary action as needed. Conduct regularly scheduled one-on-one meetings with personnel. • Coordinate team-specific orientation and training. • Manage inbound referrals to CM and appropriately triage them to facilitate CM process. • Serve as interdepartmental liaison for issues relate to CM/Outreach services. • Network with other departments to gather and/or share information. • Assist with development of Case Management/Outreach processes that facilitate cost-effective service utilization and appropriate levels of care. • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=486643&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=486643&B_ID=20&fid=1 Wed, 21 Jul 2010 00:00:00 GMT Job Summary: Assist with Medical Management Processes. Responsible for collection and entry of demographic and service requests information from providers/members into the electronic record. Verify eligibility, enrollment history and demographics of members. Act as point of contact providing medical management assistance to providers and members by maintaining communication through a telephonic and electronic and education/assistance in prior authorization requests. Essential Functions: • Convert information obtained from providers/members, (received via fax, phone or mail) into electronic records. • Facilitate/assist the authorization of benefits for out-of-network providers including completion of appropriate forms that are distributed to physicians’ offices, provider relations and the generation of approval letters. • Assist with authorizations as directed by desk references • Complete necessary contact with provider/member to verify newborn information. • Input required data into system for newborns. o Provide authorization number to provider or facility. o Assist PCC team support as directed • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=476676&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=476676&B_ID=20&fid=1 Thu, 15 Jul 2010 00:00:00 GMT Job Summary: Assist with Medical Management Processes. Responsible for collection and entry of demographic and service requests information from providers/members into the electronic record. Verify eligibility, enrollment history and demographics of members. Act as point of contact providing medical management assistance to providers and members by maintaining communication through a telephonic and electronic and education/assistance in prior authorization requests. Essential Functions: • Convert information obtained from providers/members, (received via fax, phone or mail) into electronic records. • Facilitate/assist the authorization of benefits for out-of-network providers including completion of appropriate forms that are distributed to physicians’ offices, provider relations and the generation of approval letters. • Assist with authorizations as directed by desk references • Complete necessary contact with provider/member to verify newborn information. • Input required data into system for newborns. o Provide authorization number to provider or facility. o Assist PCC team support as directed • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=485785&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=485785&B_ID=20&fid=1 Thu, 15 Jul 2010 00:00:00 GMT Job Summary: Coordinate the care, services and health benefits for selected member populations across the continuum of illness. Monitor and promote effect utilization of healthcare resources through clinical variance and benefits management. Essential Functions: • Develop and implement care plan, defining specific issues, goals and interventions as agreed to by all parties. • Monitor and evaluate care plan on an ongoing basis through member, family and treatment team contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician. • Assist in education of members regarding healthcare access and benefits, and provide members with health education and wellness materials. • Participate in meetings with providers to inform them of Case Management services and benefits available to members. • Complete assessments by gathering information from the member, family and treatment team. • Arrange and coordinate services with other healthcare disciplines while maximizing utilization of appropriate community resources and support groups. • Verify eligibility, previous enrollment history, demographics and current health status of each member. • Maintain current and accurate documentation of telephonic contacts, treatment plans, case notes, referrals, and assessments in Case Management electronic record. • Maintain appropriate documentation within protocols and guidelines of the Case Management program. • Perform any other job related instructions as requested, with reasonable accommodation. • Precepting and or mentoring new staff https://www.appone.com/MainInfoReq.asp?R_ID=486466&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=486466&B_ID=20&fid=1 Thu, 15 Jul 2010 00:00:00 GMT Job Summary: Coordinate the care, services and health benefits for selected member populations across the continuum of illness. Monitor and promote effect utilization of healthcare resources through clinical variance and benefits management. Essential Functions: • Develop and implement care plan, defining specific issues, goals and interventions as agreed to by all parties. • Monitor and evaluate care plan on an ongoing basis through member, family and treatment team contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician. • Assist in education of members regarding healthcare access and benefits, and provide members with health education and wellness materials. • Participate in meetings with providers to inform them of Case Management services and benefits available to members. • Complete assessments by gathering information from the member, family and treatment team. • Arrange and coordinate services with other healthcare disciplines while maximizing utilization of appropriate community resources and support groups. • Verify eligibility, previous enrollment history, demographics and current health status of each member. • Maintain current and accurate documentation of telephonic contacts, treatment plans, case notes, referrals, and assessments in Case Management electronic record. • Maintain appropriate documentation within protocols and guidelines of the Case Management program. • Perform any other job related instructions as requested, with reasonable accommodation. • Precepting and or mentoring new staff https://www.appone.com/MainInfoReq.asp?R_ID=486479&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=486479&B_ID=20&fid=1 Thu, 15 Jul 2010 00:00:00 GMT Job Summary: To be the primary contact for hospital/ancillary provider relations and liaison activities between facilities/ancillary providers and CareSource. To recruit, negotiate and contract with new and existing ancillary providers to improve in-network access to services and obtain optimal compensation rates. Essential Functions: • Facilitate a high level of communication and service for hospital and ancillary providers to ensure they are CareSource advocates and that their issues are resolved according to Network Operations Customer Service Expectations. • Participate in operational meetings on a regular basis and work as liaison with CareSource to ensure that issues are fully analyzed and resolved in an expeditious manner. • Negotiate or renegotiate contract language and rates for delivery of services from ancillary providers. • Work collaboratively with Hospital Contractor and PR Directors to ensure continuous performance improvement to improve customer satisfaction and internal operations. • Identify and communicate health plan issues/position as well as the hospital/ancillary providers’ issues/position in contract negotiations. • Coordinate meetings and facilitate communication with CareSource staff or departments and provider as appropriate. • Identify provider contract changes or exceptions in contract amendment format and discuss needs with Hospital Contractor. • Prepare final and maintenance contract documents for hospital/ancillary providers and health plan signature. • Ensure executed contract rates and ancillary provider demographic data are set up correctly in claims database. • Ensure that hospital provider demographic data are set up correctly in all CareSource systems. • Prepare analysis to assist in the review of provider performance. • Manage on-going relationships with assigned hospital/ancillary providers with unique or complex agreements. • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=484088&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=484088&B_ID=20&fid=1 Mon, 12 Jul 2010 00:00:00 GMT Job Summary: Coordinate the care, services and health benefits for selected member populations across the continuum of illness. Monitor and promote effect utilization of healthcare resources through clinical variance and benefits management. Essential Functions: • Develop and implement care plan, defining specific issues, goals and interventions as agreed to by all parties. • Monitor and evaluate care plan on an ongoing basis through member, family and treatment team contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician. • Assist in education of members regarding healthcare access and benefits, and provide members with health education and wellness materials. • Participate in meetings with providers to inform them of Case Management services and benefits available to members. • Complete assessments by gathering information from the member, family and treatment team. • Arrange and coordinate services with other healthcare disciplines while maximizing utilization of appropriate community resources and support groups. • Verify eligibility, previous enrollment history, demographics and current health status of each member. • Maintain current and accurate documentation of telephonic contacts, treatment plans, case notes, referrals, and assessments in Case Management electronic record. • Maintain appropriate documentation within protocols and guidelines of the Case Management program. • Perform any other job related instructions as requested, with reasonable accommodation. • Precepting and or mentoring new staff https://www.appone.com/MainInfoReq.asp?R_ID=486436&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=486436&B_ID=20&fid=1 Sat, 10 Jul 2010 00:00:00 GMT Job Summary: Coordinate the care, services and health benefits for selected member populations across the continuum of illness. Monitor and promote effect utilization of healthcare resources through clinical variance and benefits management. Essential Functions: • Develop and implement care plan, defining specific issues, goals and interventions as agreed to by all parties. • Monitor and evaluate care plan on an ongoing basis through member, family and treatment team contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician. • Assist in education of members regarding healthcare access and benefits, and provide members with health education and wellness materials. • Participate in meetings with providers to inform them of Case Management services and benefits available to members. • Complete assessments by gathering information from the member, family and treatment team. • Arrange and coordinate services with other healthcare disciplines while maximizing utilization of appropriate community resources and support groups. • Verify eligibility, previous enrollment history, demographics and current health status of each member. • Maintain current and accurate documentation of telephonic contacts, treatment plans, case notes, referrals, and assessments in Case Management electronic record. • Maintain appropriate documentation within protocols and guidelines of the Case Management program. • Perform any other job related instructions as requested, with reasonable accommodation. • Precepting and or mentoring new staff https://www.appone.com/MainInfoReq.asp?R_ID=486448&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=486448&B_ID=20&fid=1 Sat, 10 Jul 2010 00:00:00 GMT Job Summary: Facilitate and evaluate courses on a variety of business and interpersonal skills topics. Assist in the development on new courses based on needs analysis outcomes. Essential Functions: • Facilitate, and evaluate courses on a variety of topics such as, communication skills, customer service, constructive feedback, working in teams, emotional intelligence, etc. • Prepare and facilitate technical tools (Outlook, the Source, managed care) training for new hires • Assist in the development and maintenance of CareSource University Course Catalog and other communication tools • Assist with the development of new courses • Research developments in the fields of training, organizational development, career development and performance improvement https://www.appone.com/MainInfoReq.asp?R_ID=484988&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=484988&B_ID=20&fid=1 Fri, 09 Jul 2010 00:00:00 GMT Job Summary: Customer Service Representative I will assist Medicaid and Medicare members/providers with benefit, claims, and other inquiries. The CSR I provides quality service by immediately responding to the member and/or providers requests and complaints, and appropriately routing issues to the correct department for timely resolution. CSR’s are also required to capture member grievance, and relay appeals instructions for the appropriate line of business, including future lines of business. Essential Functions: • Assist members with routine servicing inquires including but not limited to; selecting a primary care physician, member benefit education, member identification cards, transportation arrangements, issues with provider accessibility, eligibility inquires, resolving member complaints, identifying and filing member grievances. • Assist a provider with routine servicing inquires including but not limited to; verifying eligibility, explanation of benefits, claims and appeal procedures. • Ensuring all HIPAA and State requirements/regulations are adhered too at all times, in existing and future lines of business. • Research, follow up, and resolve all open/pending issues in a timely manner to ensure member satisfaction. • Build and strengthen member relationships by providing quality customer service. • Maintain knowledge and understanding of all processes and procedures. • Adhere to all departmental and company policies and procedures. • Maintain complete and accurate documentation of all of telephone and written communications. • Act as a mentor to new hire employees. • Screen members to determine Case Management needs, and refer when appropriate. • Appropriately route calls to support departments including Pharmacy, and Triage, for proper/expedited resolution. • Assist with non phone work such as incoming faxes and web inquires. https://www.appone.com/MainInfoReq.asp?R_ID=479631&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=479631&B_ID=20&fid=1 Tue, 06 Jul 2010 00:00:00 GMT Job Summary: Customer Service Representative I will assist Medicaid and Medicare members/providers with benefit, claims, and other inquiries. The CSR I provides quality service by immediately responding to the member and/or providers requests and complaints, and appropriately routing issues to the correct department for timely resolution. CSR’s are also required to capture member grievance, and relay appeals instructions for the appropriate line of business, including future lines of business. Essential Functions: • Assist members with routine servicing inquires including but not limited to; selecting a primary care physician, member benefit education, member identification cards, transportation arrangements, issues with provider accessibility, eligibility inquires, resolving member complaints, identifying and filing member grievances. • Assist a provider with routine servicing inquires including but not limited to; verifying eligibility, explanation of benefits, claims and appeal procedures. • Ensuring all HIPAA and State requirements/regulations are adhered too at all times, in existing and future lines of business. • Research, follow up, and resolve all open/pending issues in a timely manner to ensure member satisfaction. • Build and strengthen member relationships by providing quality customer service. • Maintain knowledge and understanding of all processes and procedures. • Adhere to all departmental and company policies and procedures. • Maintain complete and accurate documentation of all of telephone and written communications. • Act as a mentor to new hire employees. • Screen members to determine Case Management needs, and refer when appropriate. • Appropriately route calls to support departments including Pharmacy, and Triage, for proper/expedited resolution. • Assist with non phone work such as incoming faxes and web inquires. https://www.appone.com/MainInfoReq.asp?R_ID=482927&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=482927&B_ID=20&fid=1 Tue, 06 Jul 2010 00:00:00 GMT Job Summary: Customer Service Representative I will assist Medicaid and Medicare members/providers with benefit, claims, and other inquiries. The CSR I provides quality service by immediately responding to the member and/or providers requests and complaints, and appropriately routing issues to the correct department for timely resolution. CSR’s are also required to capture member grievance, and relay appeals instructions for the appropriate line of business, including future lines of business. Essential Functions: • Assist members with routine servicing inquires including but not limited to; selecting a primary care physician, member benefit education, member identification cards, transportation arrangements, issues with provider accessibility, eligibility inquires, resolving member complaints, identifying and filing member grievances. • Assist a provider with routine servicing inquires including but not limited to; verifying eligibility, explanation of benefits, claims and appeal procedures. • Ensuring all HIPAA and State requirements/regulations are adhered too at all times, in existing and future lines of business. • Research, follow up, and resolve all open/pending issues in a timely manner to ensure member satisfaction. • Build and strengthen member relationships by providing quality customer service. • Maintain knowledge and understanding of all processes and procedures. • Adhere to all departmental and company policies and procedures. • Maintain complete and accurate documentation of all of telephone and written communications. • Act as a mentor to new hire employees. • Screen members to determine Case Management needs, and refer when appropriate. • Appropriately route calls to support departments including Pharmacy, and Triage, for proper/expedited resolution. • Assist with non phone work such as incoming faxes and web inquires. https://www.appone.com/MainInfoReq.asp?R_ID=483157&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=483157&B_ID=20&fid=1 Tue, 06 Jul 2010 00:00:00 GMT Job Summary: Responsible for utilization review and discharge planning activities for members enrolled with a CareSource Management Group (CareSource) line of business, monitoring the appropriate delivery of health care services in a cost effective manner. Maintain knowledge of State and Federal regulations governing CareSource, State Contracts and Provider Agreement, benefits and URAC Standards. Essential Functions: • Prospective, retrospective and concurrent review of inpatient admissions, outpatient procedures, homecare services and durable medical equipment. • Coordinate care and facilitate discharge to an appropriate level of care in a timely and cost-effective manner. • Identify and refer quality issues to Quality Improvement. • Identify and refer appropriate members for Case Management. • Document and communicate with CareSource and Provider Case Managers and Discharge Planners to establish discharge planning needs and coordinate care. • Perform any other job related instructions as requested, with reasonable accommodation. • Provide direction to non-clinical medical management staff. • RN’s - Provide direction to and assist with oversight of LPN, LISW medical management staff. https://www.appone.com/MainInfoReq.asp?R_ID=465975&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=465975&B_ID=20&fid=1 Mon, 05 Jul 2010 00:00:00 GMT To establish and maintain enrollment information on plan members in accordance with established policies and procedures. https://www.appone.com/MainInfoReq.asp?R_ID=483358&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=483358&B_ID=20&fid=1 Tue, 29 Jun 2010 00:00:00 GMT Job Summary: Utilize skills and experience to investigate potential COB (Coordination of Benefits) information related to claims payment. Update Facets claims processing system with new information and perform ongoing maintenance of member COB data. Essential Functions: • Perform COB verifications by calling carriers and performing online verifications to obtain coverage effective and/or termination dates for members. • Identify and verify potential COB using claim submissions, e-mail, faxes, and state TPL files. • Using Prior Authorization data from Medical Management, investigate potential COB on any members meeting established criteria. • Enter COB and performance maintenance of information including carrier name, policy number, and effective/termination dates within Facets claims system. • Maintain insurance carrier contact list. • Submit notifications and maintain log for refund requests sent to providers. • Perform special projects related to COB per management assignment. • Identify potential process improvements and participate in related initiatives. • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=479291&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=479291&B_ID=20&fid=1 Tue, 29 Jun 2010 00:00:00 GMT Job Summary: Use decision support software in order to perform telephonic clinical health information services for CareSource managed health plans and external clients. Coordinate the care, services and health benefits for selected member populations across the continuum of illness. Monitor and promote effect utilization of healthcare resources through clinical variance and benefits management. Essential Functions: • Complete member assessments by gathering information from the member, family and treatment team. • Develop care plan, defining specific issues, goals and interventions as agreed to by all parties. • Assist in education of members regarding healthcare access and benefits, and provide members with health education and wellness materials. • Verify eligibility, previous enrollment history, demographics and current health status of each member. • Maintain current and accurate documentation of telephonic contacts, treatment plans, case notes, referrals, and assessments in Case Management electronic record. • Maintain appropriate documentation within protocols and guidelines of the Case Management program. • Perform any other job related instructions as requested, with reasonable accommodation. • Participate in learning activities for Case Management proficiency https://www.appone.com/MainInfoReq.asp?R_ID=484697&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=484697&B_ID=20&fid=1 Mon, 28 Jun 2010 00:00:00 GMT Job Summary: Coordinate the care, services and health benefits for selected member populations across the continuum of illness. Monitor and promote effect utilization of healthcare resources through clinical variance and benefits management. Essential Functions: • Develop and implement care plan, defining specific issues, goals and interventions as agreed to by all parties. • Monitor and evaluate care plan on an ongoing basis through member, family and treatment team contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician. • Assist in education of members regarding healthcare access and benefits, and provide members with health education and wellness materials. • Participate in meetings with providers to inform them of Case Management services and benefits available to members. • Complete assessments by gathering information from the member, family and treatment team. • Arrange and coordinate services with other healthcare disciplines while maximizing utilization of appropriate community resources and support groups. • Verify eligibility, previous enrollment history, demographics and current health status of each member. • Maintain current and accurate documentation of telephonic contacts, treatment plans, case notes, referrals, and assessments in Case Management electronic record. • Maintain appropriate documentation within protocols and guidelines of the Case Management program. • Perform any other job related instructions as requested, with reasonable accommodation. • Precepting and or mentoring new staff https://www.appone.com/MainInfoReq.asp?R_ID=483622&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=483622&B_ID=20&fid=1 Thu, 24 Jun 2010 00:00:00 GMT Job Summary: The senior data analyst will lead projects that involve working closely with the business to define, document, and apply business rules to enterprise data. They will also design and develop data standards, policies, procedures, and metadata to ensure accuracy, quality, integrity, and optimization of this data. This includes working closely with application and database developers to model existing undocumented databases as well as designing new application databases. Responsibilities also include researching and documenting data requirements for regulatory data submissions and designing database models that facilitate reporting and analysis. Essential Functions: • Develop enterprise data policies and standards and monitor adherence to these standards. • Guide, mentor, and instruct more junior staff members regarding enterprise data management practices. • Ensure the quality of data submitted to regulatory agencies by developing detailed metadata for submissions and monitoring these submissions on an ongoing basis. • Design data models for reporting and analytic databases that translate business and regulatory rules and definitions into query able data structures. • Design data models for development of new transactional systems. • Reverse engineer data models for existing databases and systems. • Design and implement procedures that monitor enterprise data quality and take appropriate action when anomalies occur. • Develop and maintain detailed documentation that provides traceability for all enterprise data back to its source. • Actively participate in projects designed to create record of reference systems for key enterprise data. • Define and adhere to standard metadata naming conventions. https://www.appone.com/MainInfoReq.asp?R_ID=480691&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=480691&B_ID=20&fid=1 Wed, 23 Jun 2010 00:00:00 GMT Job Summary: Coordinate the care, services and health benefits for selected member populations across the continuum of illness. Monitor and promote effect utilization of healthcare resources through clinical variance and benefits management. Essential Functions: • Develop and implement care plan, defining specific issues, goals and interventions as agreed to by all parties. • Monitor and evaluate care plan on an ongoing basis through member, family and treatment team contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician. • Assist in education of members regarding healthcare access and benefits, and provide members with health education and wellness materials. • Participate in meetings with providers to inform them of Case Management services and benefits available to members. • Complete assessments by gathering information from the member, family and treatment team. • Arrange and coordinate services with other healthcare disciplines while maximizing utilization of appropriate community resources and support groups. • Verify eligibility, previous enrollment history, demographics and current health status of each member. • Maintain current and accurate documentation of telephonic contacts, treatment plans, case notes, referrals, and assessments in Case Management electronic record. • Maintain appropriate documentation within protocols and guidelines of the Case Management program. • Perform any other job related instructions as requested, with reasonable accommodation. • Precepting and or mentoring new staff https://www.appone.com/MainInfoReq.asp?R_ID=482368&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=482368&B_ID=20&fid=1 Fri, 18 Jun 2010 00:00:00 GMT Job Summary: Coordinate the care, services and health benefits for selected member populations across the continuum of illness. Monitor and promote effect utilization of healthcare resources through clinical variance and benefits management. Essential Functions: • Develop and implement care plan, defining specific issues, goals and interventions as agreed to by all parties. • Monitor and evaluate care plan on an ongoing basis through member, family and treatment team contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician. • Assist in education of members regarding healthcare access and benefits, and provide members with health education and wellness materials. • Participate in meetings with providers to inform them of Case Management services and benefits available to members. • Complete assessments by gathering information from the member, family and treatment team. • Arrange and coordinate services with other healthcare disciplines while maximizing utilization of appropriate community resources and support groups. • Verify eligibility, previous enrollment history, demographics and current health status of each member. • Maintain current and accurate documentation of telephonic contacts, treatment plans, case notes, referrals, and assessments in Case Management electronic record. • Maintain appropriate documentation within protocols and guidelines of the Case Management program. • Perform any other job related instructions as requested, with reasonable accommodation. • Precepting and or mentoring new staff https://www.appone.com/MainInfoReq.asp?R_ID=482374&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=482374&B_ID=20&fid=1 Fri, 18 Jun 2010 00:00:00 GMT Job Summary: Responsible for working with RN to coordinate the care, services and health benefits for selected member populations across the continuum of illness. Monitor and promote effective utilization of healthcare resources within the scope of the LPN licensure. Essential Functions: • Assists with collection of data to contribute towards the completion of assessments. Collaborates closely with the RN to ensure compliance with department policies/procedures. • Monitors and educates the member specific to the member’s plan of care. • May assist with requests for coordination of transportation benefit. • May assist with outreach efforts for coordination of care or benefits. • Perform any other job related instructions as requested, with reasonable accommodation. • Travel or on-site placement may be required. https://www.appone.com/MainInfoReq.asp?R_ID=482381&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=482381&B_ID=20&fid=1 Fri, 18 Jun 2010 00:00:00 GMT Use decision support software in order to perform telephonic clinical triage and health information services for CSMG managed health plans and external clients. Function as a patient advocate by facilitating accessibility to healthcare and provide collaborative services for other CSMG departments. https://www.appone.com/MainInfoReq.asp?R_ID=477370&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=477370&B_ID=20&fid=1 Thu, 17 Jun 2010 00:00:00 GMT Job Summary: The Provider Resolution Specialist is responsible for capturing, resolving/facilitating resolution, and reporting on escalated complaints regarding claims processing, provider dissatisfaction with payment and denial explanations. This individual will be responsible for identifying trends and recommending improvements related to provider inquires and complaints. Essential Functions: • Ensure that all assigned provider issues are resolved and communicated to the provider within appropriate timeframes and report resolutions that are unfavorable to the appropriate Provider Relations Representative. • Assist providers with escalated inquiries including but not limited to; verifying proper medical coding, explanation of benefits, negative balance requests, claims, and appeal procedures. • Work with Decision Support Informatics (DSI) to develop reporting on provider complaints and inquires and develop recommendations to proactively address complaints and reduce unwarranted inquires. • Examine and identify data to improve plan performance, internal processes and department workflow. Present improvement recommendations and provider education topics to the Operations Enterprise Committee. • Participate in meetings related to claims processing and payment decisions such as, Reimbursement and Benefit and Provider Appeals Workgroup. • Document all inquires and complaints completely and thoroughly. • Identify and lead departmental training and communication as needed. • Ensure reporting on provider inquires and complaints is compliant with current and future regulatory and accreditation bodies such as; ODJFS, MDCH, CMS, OFIR, NCQA and URAC. • Adhere to all HIPAA, State, and Federal requirements and regulations at all times in existing and future lines of business. • Perform any other job related instructions as requested, with reasonable accommodation https://www.appone.com/MainInfoReq.asp?R_ID=481553&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=481553&B_ID=20&fid=1 Thu, 10 Jun 2010 00:00:00 GMT Job Summary: A Customer Service Representative III acts as subject matter expert, while staffing the assist line and accurately responding to inquires presented by a CSR I and II who is servicing Medicaid/Medicare member or provider, including members and providers associated with future lines of business. The CSR III also monitors queue performance, makes necessary staffing adjustments to the queues during peak periods, tracks call trends, and alerts management when necessary. Essential Functions: • Monitor and manage call queues to ensure all Customer Service Representatives are available and appropriately staffed. • Act as a “New Hire Coach” for new employees. • Maintain Outage log and report to management team weekly. • Provide Peer to Peer feedback (daily phone interaction). • Identify training needs for Service Center Representatives. • Manage and process internal route boxes. • Ability to service both member and provider calls in all lines of business, existing and future. • Utilize self-education opportunities to stay abreast of procedural updates – maintain Subject Matter Expert (SME) status in all skill sets. • Act as a mentor to new hire employees. • Answer second level assist questions. • Willingness and ability to assist Customer Service Representatives with questions and inquires. • Document all second level support questions by utilizing and maintaining the Assist Line Tracking Database. • Handle and resolve escalated member and provider complaints. • Act as a role model to other Customer Service Representatives and employees. • Display a positive attitude. • Be helpful and approachable to other Customer Service Representatives and employees. • Be accountable for actions. • Motivate other Customer Service Representatives and employees. • Assist members with routine servicing inquires including but not limited to; selecting a primary care physician, member benefit education, member identification cards, transportation arrangements, issues with provider accessibility, eligibility inquires, member complaints, identifying and filing member grievances. • Assist providers with routine servicing inquires including but not limited to; verifying eligibility, explanation of benefits, claims and appeal procedures. • Ensuring all HIPAA and State requirements/regulations are adhered too at all times in existing and future lines of business. • Research, follow up and resolve all open/pending issues in a timely manner to ensure member satisfaction. • Build and strengthen member relationships by providing quality customer service. • Maintain knowledge and understanding of all processes and procedures. • Adhere to all policies and procedures. • Maintain complete and accurate documentation of all of telephone and written communications. • Screen members to determine if they need Case Management and refer when appropriate. • Route calls to appropriate departments including Pharmacy, and Triage, for proper/ex https://www.appone.com/MainInfoReq.asp?R_ID=479652&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=479652&B_ID=20&fid=1 Thu, 10 Jun 2010 00:00:00 GMT Job Summary: Develop unique and innovative enterprise wide, graphics based, reporting solutions that deliver actionable information to the business with a high degree of impact. Perform analysis as needed to support business decision-making. Reporting application development in the SAS Information Delivery Portal will involve database programming, stored process development, both server and client side web development, as well as significant use of the SAS Business Intelligence suite of software including Information Data Map Studio, Web Report Studio, OLAP studio and others. Use BASE SAS to develop graphical output (charts, graphs, control charts, custom graphics, custom reports) for delivery via the SAS Portal. Essential Functions: • Develop, and implement Information delivery solutions in SAS for the purpose of providing business intelligence. • Develop code that graphically represents data in a manner that is user friendly, fully automatable, and supportable. • Incorporate critical thinking skills and judgment in the analysis process to determine best course of action for each inquiry/problem. • Follow established department coding, documentation, and testing standards and procedures. • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=478723&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=478723&B_ID=20&fid=1 Sun, 06 Jun 2010 00:00:00 GMT Job Summary: Responsible for multistate provider service and satisfaction and ongoing formal communication of policy changes and other pertinent information. Responsible for corporate level performance improvement of all operations that touch providers. Essential Functions: • Multistate travel a minimum of 50% of time • Develop External Relations strategy and program on an annual basis and monitor key metrics at staff level to ensure a high quality of service delivery • Ensure adherence to Network Operations Customer Service Standards • Provide Network Operations representation and leadership for CareSource Programs such as Health Care Home, HEDIS etc. • Coordination and attendance of multistate Office Manager Forums, Provider Advisory Councils and Key Joint Operating Committees • Conduct joint provider visits with External Relations Managers and Hospital Service Reps a minimum of monthly to provide mentoring, oversight and direct contact with key providers. • Conduct joint provider visits with External Provider Relations Representatives and External Relations Managers a minimum of once per quarter • Conduct joint provider calls with Internal Provider Relations Representatives and External Relations Managers a minimum of once per quarter • Responsible for Provider Communications to include notification and tracking of policy change, Provider Portal and Provider Newsletters in conjunction with Corporate Communications • Implement performance improvement initiatives to improve Provider Satisfaction Scores incrementally on an annual basis • Support Contracting Team as necessary when recruitment needs dictate to include travel to expansion areas if needed • Make certain the provider network is cost effective, competitive, and stable • In collaboration with Contracting, Credentialing and Provider Data Integrity Directors, formulate agendas and conduct Network Operations Staff Meetings https://www.appone.com/MainInfoReq.asp?R_ID=480304&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=480304&B_ID=20&fid=1 Thu, 03 Jun 2010 00:00:00 GMT Job Summary: Project Coordinator is the initial position on the project management career path that is responsible for interacting with the Project and Program Managers to organize the various components needed to initiate, run and conclude projects Essential Functions: • Demonstrate aptitude for team management to motivate, drive collaboration and assess performance. • Learn to assess, prioritize and mitigate project risks • Assist in project-chartering process and setup • Follow defined project management processes • Develop and maintain Microsoft project schedules • Track project milestones and deliverables . Track short-term project metrics (for example, schedule variances and customer satisfaction) • Coordinate / facilitate project team meetings • Identify and organize project communications to ensure consistency with client business objectives • Update Project Office work queue with current project highlights • Assist in the preparation of presentations and briefing materials to summarize project scope, status, issues, etc. • Track and report to Project/Program Manager and/or Management on project status • Produce detailed reports, business decision documents and notifications as appropriate. • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=466807&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=466807&B_ID=20&fid=1 Thu, 03 Jun 2010 00:00:00 GMT Job Summary: Responsible for the integrity and accurate reporting of the financial position of the CareSource Management Group Company and all affiliated entities Essential Functions: • Ensures financial stewardship for CareSource’s entities by establishing, monitoring and enforcing financial policies and procedures and internal controls. Includes leadership for ensuring the integrity and security of the general ledger and reporting system. • Provides timely, accurate comprehensive and transparent financial reporting including, but not limited to, operating statements, balance sheets, cash flow statements, and key business reports as required in accordance with generally accepted accounting principles and statutory requirements. • Responsible for all statutory financial statement filings for the regulated entities • Manage fiduciary responsibilities for corporate assets. • Coordinates independent financial accounting audits and other regulatory financial related audits. • Proactively researches existing and new legislation, changes in financial accounting standards and NAIC statutory requirements. • Responsible for the management of the accounting staff • Ability to interact with all levels of management as well as external audit management. • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=481188&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=481188&B_ID=20&fid=1 Sat, 29 May 2010 00:00:00 GMT Job Summary: Responsible for the integrity and accurate accounting and reporting of the financial position of multiple entities within the CareSource Management Group Company family and the consolidated entity, and ensure operations are in accordance with reporting requirements and appropriate internal controls. Essential Functions: • Prepare and review consolidated monthly financial statement for CareSource Management Group Company. Also, prepare and review monthly financial statements for CareSource Foundation, CareSource Indiana, and CareSource Insurance LLC. • Coordinate SNP reporting for CSO and CSM. Collaborate with CSO Accounting Manager and CSM Accounting Manager as necessary. • Perform monthly CareSource cost allocations in accordance with executed Management Agreements. • Prepare and implement all necessary internal controls for related entities consistent with Model Audit Rule requirements. • Administer audit and report functions, as required. • Collaborate with the Treasurer in the oversight of Corporate Credit Card program and employee expense reimbursement. • Oversee responsibility for corporate fixed asset accounting and reporting. • Coordinate with the CFO and Director of Internal Audit in the independent financial accounting audits of the consolidated GAAP entity. • Ensure on-time filing of all internal and external financial reporting. • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=480264&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=480264&B_ID=20&fid=1 Fri, 28 May 2010 00:00:00 GMT Job Summary: Responsible for the integrity and accurate accounting and reporting of the financial position of an area(s)/plan of CareSource, and ensure operations are managed in accordance with regulatory and reporting requirements. Essential Functions: • Prepare and review monthly financial statements, supporting journals, and supplementary schedules. • Maintain compliance with plan reporting requirements to state department of insurance, Medicaid administrator, and department of insurance. • Administer audit and report functions, as required. • Collaborate with the Treasurer in the oversight of investment reporting and performance. • Manage fiduciary responsibilities for plan assets. • Coordinate with the CFO and Director of Internal Audit in the independent financial accounting audits and other regulatory financial related audits pertinent to the plan. • Maintain up to date knowledge of statutory and GAAP accounting. • Perform any other job related instructions as requested, with reasonable accommodation. • ~10% travel required. https://www.appone.com/MainInfoReq.asp?R_ID=480262&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=480262&B_ID=20&fid=1 Fri, 28 May 2010 00:00:00 GMT Identify and assess available resources to meet the social needs that affect a member’s medical condition, treatment, recovery and transition to a lower level of care. Assure that members and families are knowledgeable of available community resources and how to access them. Serve as a resource to clinical staff in dealing with complex psychosocial issues and accessing community resources. Develop and maintain community resources. Provide education on Social Services issues. https://www.appone.com/MainInfoReq.asp?R_ID=477756&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=477756&B_ID=20&fid=1 Mon, 24 May 2010 00:00:00 GMT Job Summary: Assist with Medical Management Processes. Responsible for collection and entry of demographic and service requests information from providers/members into the electronic record. Verify eligibility, enrollment history and demographics of members. Act as point of contact providing medical management assistance to providers and members by maintaining communication through a telephonic and electronic and education/assistance in prior authorization requests. Essential Functions: • Convert information obtained from providers/members, (received via fax, phone or mail) into electronic records. • Facilitate/assist the authorization of benefits for out-of-network providers including completion of appropriate forms that are distributed to physicians’ offices, provider relations and the generation of approval letters. • Assist with authorizations as directed by desk references • Complete necessary contact with provider/member to verify newborn information. • Input required data into system for newborns. o Provide authorization number to provider or facility. o Assist PCC team support as directed • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=474199&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=474199&B_ID=20&fid=1 Mon, 24 May 2010 00:00:00 GMT Job Summary: Responsible for working with RN to coordinate the care, services and health benefits for selected member populations across the continuum of illness. Monitor and promote effective utilization of healthcare resources within the scope of the LPN licensure. Essential Functions: • Assists with collection of data to contribute towards the completion of assessments. Collaborates closely with the RN to ensure compliance with department policies/procedures. • Monitors and educates the member specific to the member’s plan of care. • May assist with requests for coordination of transportation benefit. • May assist with outreach efforts for coordination of care or benefits. • Perform any other job related instructions as requested, with reasonable accommodation. • Travel or on-site placement may be required. https://www.appone.com/MainInfoReq.asp?R_ID=477583&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=477583&B_ID=20&fid=1 Mon, 24 May 2010 00:00:00 GMT Job Summary: A Customer Service Representative III acts as subject matter expert, while staffing the assist line and accurately responding to inquires presented by a CSR I and II who is servicing Medicaid/Medicare member or provider, including members and providers associated with future lines of business. The CSR III also monitors queue performance, makes necessary staffing adjustments to the queues during peak periods, tracks call trends, and alerts management when necessary. Essential Functions: • Monitor and manage call queues to ensure all Customer Service Representatives are available and appropriately staffed. • Act as a “New Hire Coach” for new employees. • Maintain Outage log and report to management team weekly. • Provide Peer to Peer feedback (daily phone interaction). • Identify training needs for Service Center Representatives. • Manage and process internal route boxes. • Ability to service both member and provider calls in all lines of business, existing and future. • Utilize self-education opportunities to stay abreast of procedural updates – maintain Subject Matter Expert (SME) status in all skill sets. • Act as a mentor to new hire employees. • Answer second level assist questions. • Willingness and ability to assist Customer Service Representatives with questions and inquires. • Document all second level support questions by utilizing and maintaining the Assist Line Tracking Database. • Handle and resolve escalated member and provider complaints. • Act as a role model to other Customer Service Representatives and employees. • Display a positive attitude. • Be helpful and approachable to other Customer Service Representatives and employees. • Be accountable for actions. • Motivate other Customer Service Representatives and employees. • Assist members with routine servicing inquires including but not limited to; selecting a primary care physician, member benefit education, member identification cards, transportation arrangements, issues with provider accessibility, eligibility inquires, member complaints, identifying and filing member grievances. • Assist providers with routine servicing inquires including but not limited to; verifying eligibility, explanation of benefits, claims and appeal procedures. • Ensuring all HIPAA and State requirements/regulations are adhered too at all times in existing and future lines of business. • Research, follow up and resolve all open/pending issues in a timely manner to ensure member satisfaction. • Build and strengthen member relationships by providing quality customer service. • Maintain knowledge and understanding of all processes and procedures. • Adhere to all policies and procedures. • Maintain complete and accurate documentation of all of telephone and written communications. • Screen members to determine if they need Case Management and refer when appropriate. • Route calls to appropriate departments including Pharmacy, and Triage, for proper/ex https://www.appone.com/MainInfoReq.asp?R_ID=478244&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=478244&B_ID=20&fid=1 Sun, 23 May 2010 00:00:00 GMT Job Summary: A Customer Service Representative III acts as subject matter expert, while staffing the assist line and accurately responding to inquires presented by a CSR I and II who is servicing Medicaid/Medicare member or provider, including members and providers associated with future lines of business. The CSR III also monitors queue performance, makes necessary staffing adjustments to the queues during peak periods, tracks call trends, and alerts management when necessary. Essential Functions: • Monitor and manage call queues to ensure all Customer Service Representatives are available and appropriately staffed. • Act as a “New Hire Coach” for new employees. • Maintain Outage log and report to management team weekly. • Provide Peer to Peer feedback (daily phone interaction). • Identify training needs for Service Center Representatives. • Manage and process internal route boxes. • Ability to service both member and provider calls in all lines of business, existing and future. • Utilize self-education opportunities to stay abreast of procedural updates – maintain Subject Matter Expert (SME) status in all skill sets. • Act as a mentor to new hire employees. • Answer second level assist questions. • Willingness and ability to assist Customer Service Representatives with questions and inquires. • Document all second level support questions by utilizing and maintaining the Assist Line Tracking Database. • Handle and resolve escalated member and provider complaints. • Act as a role model to other Customer Service Representatives and employees. • Display a positive attitude. • Be helpful and approachable to other Customer Service Representatives and employees. • Be accountable for actions. • Motivate other Customer Service Representatives and employees. • Assist members with routine servicing inquires including but not limited to; selecting a primary care physician, member benefit education, member identification cards, transportation arrangements, issues with provider accessibility, eligibility inquires, member complaints, identifying and filing member grievances. • Assist providers with routine servicing inquires including but not limited to; verifying eligibility, explanation of benefits, claims and appeal procedures. • Ensuring all HIPAA and State requirements/regulations are adhered too at all times in existing and future lines of business. • Research, follow up and resolve all open/pending issues in a timely manner to ensure member satisfaction. • Build and strengthen member relationships by providing quality customer service. • Maintain knowledge and understanding of all processes and procedures. • Adhere to all policies and procedures. • Maintain complete and accurate documentation of all of telephone and written communications. • Screen members to determine if they need Case Management and refer when appropriate. • Route calls to appropriate departments including Pharmacy, and Triage, for proper/ex https://www.appone.com/MainInfoReq.asp?R_ID=478893&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=478893&B_ID=20&fid=1 Sun, 23 May 2010 00:00:00 GMT Job Summary: Recruit providers for the network. Contract and educate provider offices of current CSMG policies and procedures. Maintain integrity of relationships through negotiations and contracting. Ensure consistent high level of service and provider satisfaction through visits to high volume providers and recruitment efforts and facilitate timely and effective problem resolution. Essential Functions: • Recruit and negotiate with providers in assigned region. • Provide contact point for large volume and safety net providers and seek contact with these providers so any issues may be resolved and possible issues avoided. These providers will be visited in person multiple times per year. • Review provider panel in assigned region to ensure the minimum provider panel has been satisfied in accordance with State guidelines. • Along with Internal Provider Relations Representatives notify providers of any application that is incomplete and advise provider of any changes that must be made for credentialing information to be finalized. • Ensure timelines and followup of onboarding process are occurring in timely manner. • Understand, gather and utilize market intelligence data as it applies to Network Development. • Follow approved CSMG guidelines to enable providers to become part of CSMG plan. • Educate providers on CSMG Policies and Procedures. • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=478918&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=478918&B_ID=20&fid=1 Fri, 21 May 2010 00:00:00 GMT Provide top-tier support and design of contact center and telecommunication systems. Responsible for technical design, implementation and support of voice communications infrastructure on local/wide area networks, firewalls and other network security devices. • Understanding and experience with IP and TDM based PBX/PABX and ACD systems. • Understanding of CTI middleware integration with Business Applications, such as CRM , ERP (Enterprise Resource Planning), Workforce Management, Quality Management, Outbound Dialing and Voice/Data Monitoring. • IVR Technologies - Knowledge of Cisco Voice Portal and carrier IVR/VRU systems and solutions. • Experience with XML and VXML • Knowledge of Advanced Speech Recognition and Text-to-Speech offerings • Understanding of, experience with, and exposure to messaging and personal productivity applications such as UNITY, Personal Assistant, and IP Phone Productivity Applications • Understanding of, experience with, and exposure to IP Telephony, including Cisco Unified Communications Manager (CUCM), IP Phones, XML Applications, Meeting Place, Emergency Responder, and Telephony Applications • Understanding of Cisco’s UCCE/IPCC Enterprise Solution • Hands-on experience with carrier Intelligent Network services from companies such as AT&T and Qwest, including toll-free service, network routing, call forwarding and network transfer. • Call Routing applications, including Cisco’s Intelligent Contact Manager (ICM), Voice Management, General familiarity with Microsoft Windows and LINUX/ Solaris, Cisco IOS (CIOS) • Familiarity with relational database systems, including forms-based query and data entry; SQL. • Ability to translate complex contact center business requirements into call routing designs. • Ability to program, test, and implement call routing designs. • Understanding and mastery of contact center related terminology, Key Performance Indicators (KPIs), and database items and calculations. • Ability to design highly available / fault tolerant systems for mission critical voice applications. • Mastery of assisting customers in process development for managing the system in ongoing operations mode, including system administration and backup, asset management, and scheduled maintenance. • Ensure changes to design and implementation of infrastructure solutions are capable of adapting to the growth and rapid change inherent at CareSource. • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=471273&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=471273&B_ID=20&fid=1 Fri, 21 May 2010 00:00:00 GMT Job Summary: The HR Representative will support the Human Resource operations functions including benefits administration, reporting, payroll, and qualified plan administration. The individual will have a wide range of responsibilities and will interact with employees and outside vendors. Essential Functions: • Complete initial market comparisons for job salary evaluations • Compile and review timesheets on a bi-weekly basis • Assist with preparing and finalizing contracts including version control, follow up, and filing • Compile standard reports: benefit enrollment, cost of benefits, wellness trending, etc. • Maintain benefit compliance calendar and proactively support compliance initiatives • Assist with WellZone communication and administration • Serve as back-up MySource site administrator • Assist with 401k reporting and committee follow up • Maintain and facilitate documentation and catalog of compliance documents (SPD’s, plan documents, amendments, regulatory filings) • Support administration of business interruption plan for HR • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=477077&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=477077&B_ID=20&fid=1 Tue, 18 May 2010 00:00:00 GMT Job Summary: The Human Resources Recruiter is responsible for delivering recruiting support throughout the organization. This will be achieved through the development of recruiting plans, employing traditional sourcing strategies and resources as well as developing new, creative recruiting ideas. The Human Resources Recruiter, in conjunction with the Human Resources Consultant, will play a critical role in ensuring we are hiring the best possible talent. Essential Functions: • Complete facets of recruiting cycle to assist HR Consultants. Responsibilities include posting positions (internally and externally), screening and reference checking. • Develop a pool of qualified candidates in advance of need. • Research and recommend new sources for active and passive candidate recruiting. • Build networks to find qualified passive candidates. • Post openings in newspaper advertisements, with professional organizations, and in other position appropriate venues. • Utilize the Internet for recruitment. --Post positions to appropriate Internet sources. --Improve the company website recruiting page to assist in recruiting. --Research new ways of using the Internet for recruitment. --Use social and professional networking sites to identify and source candidates. • Attend career fairs for recruiting and company recognition. • Review applicants to evaluate if they meet the position requirements. • Conduct prescreening interviews. • Assist in performing reference and background checks for potential employees. • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=477078&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=477078&B_ID=20&fid=1 Tue, 18 May 2010 00:00:00 GMT Initiate telephonic contact with new members, welcome them to the plan, convey benefit information, and perform initial health risk screening to ensure early identification of members needing case management services. Assist in education of members regarding health care access and benefits. https://www.appone.com/MainInfoReq.asp?R_ID=476941&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=476941&B_ID=20&fid=1 Sun, 09 May 2010 00:00:00 GMT Actively oversee the performance of the case management department to ensure all state requirements are achieved. Constantly monitor staff performance for quality measures, workloads and productivity outcomes. https://www.appone.com/MainInfoReq.asp?R_ID=474948&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=474948&B_ID=20&fid=1 Mon, 26 Apr 2010 00:00:00 GMT Job Summary: A Customer Service Representative III acts as subject matter expert, while staffing the assist line and accurately responding to inquires presented by a CSR I and II who is servicing Medicaid/Medicare member or provider, including members and providers associated with future lines of business. The CSR III also monitors queue performance, makes necessary staffing adjustments to the queues during peak periods, tracks call trends, and alerts management when necessary. Essential Functions: • Monitor and manage call queues to ensure all Customer Service Representatives are available and appropriately staffed. • Act as a “New Hire Coach” for new employees. • Maintain Outage log and report to management team weekly. • Provide Peer to Peer feedback (daily phone interaction). • Identify training needs for Service Center Representatives. • Manage and process internal route boxes. • Ability to service both member and provider calls in all lines of business, existing and future. • Utilize self-education opportunities to stay abreast of procedural updates – maintain Subject Matter Expert (SME) status in all skill sets. • Act as a mentor to new hire employees. • Answer second level assist questions. • Willingness and ability to assist Customer Service Representatives with questions and inquires. • Document all second level support questions by utilizing and maintaining the Assist Line Tracking Database. • Handle and resolve escalated member and provider complaints. • Act as a role model to other Customer Service Representatives and employees. • Display a positive attitude. • Be helpful and approachable to other Customer Service Representatives and employees. • Be accountable for actions. • Motivate other Customer Service Representatives and employees. • Assist members with routine servicing inquires including but not limited to; selecting a primary care physician, member benefit education, member identification cards, transportation arrangements, issues with provider accessibility, eligibility inquires, member complaints, identifying and filing member grievances. • Assist providers with routine servicing inquires including but not limited to; verifying eligibility, explanation of benefits, claims and appeal procedures. • Ensuring all HIPAA and State requirements/regulations are adhered too at all times in existing and future lines of business. • Research, follow up and resolve all open/pending issues in a timely manner to ensure member satisfaction. • Build and strengthen member relationships by providing quality customer service. • Maintain knowledge and understanding of all processes and procedures. • Adhere to all policies and procedures. • Maintain complete and accurate documentation of all of telephone and written communications. • Screen members to determine if they need Case Management and refer when appropriate. • Route calls to appropriate departments including Pharmacy, and Triage, for proper/ex https://www.appone.com/MainInfoReq.asp?R_ID=473807&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=473807&B_ID=20&fid=1 Fri, 23 Apr 2010 00:00:00 GMT Job Summary: The Community Sales and Marketing Representative will drive and achieve health plan enrollment/growth goals by managing business/community relationships for both the Medicare and Medicaid product lines within an assigned territory and consistent with state and federal regulations for both programs. Essential Functions: • The Community Sales and Marketing Representative is responsible for educating eligible consumers and the community about the CareSource Medicare/Medicaid product lines; generating enrollment leads and referrals; supporting enrollment of Medicare eligible consumers into the CareSource Medicare Advantage plan; facilitating enrollment growth in the Medicaid product; and managing CareSource’s engagement with community stakeholders and organizations focused on services to a shared client base. • Work under the direction of the Director of Marketing/Sales to drive and achieve marketing goals by leading or advancing the marketing cycle. • Contribute to the development of a viable marketing plan for the designated territory. • Serve as a subject matter expect on CareSource Medicaid/Medicare plans and product lines. • Serve as a liaison for the health plan in designated communities via community/individual education opportunities. • Develop new forums to market and educate eligible consumers and the community about CareSource products. • Conduct presentations, marketing activities and other informational events in accordance with current approved communication and marketing programs and state/federal regulations. • Participate in planning and implementation of community outreach strategies and programs in conjunction with Quality Improvement and Provider Relations staff. • Travel throughout region to provide education about the organization to promote enrollment. • Execute basic administrative duties as defined by the Director of Marketing/Sales, including updates and maintenance of appropriate reporting/database systems (funnel management, customer information, territory planning, etc.) • Maintain working knowledge of plan benefit, program changes and industry insights. • Ensure compliance and quality of marketing and outreach process components, adhering to all applicable state and federal regulatory requirements. • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=461535&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=461535&B_ID=20&fid=1 Fri, 23 Apr 2010 00:00:00 GMT Job Summary: Analyze new and existing computer systems to determine the effectiveness of their processing methods and procedures. Recommends implementation, enhancements, and operational policy guidelines as appropriate. Essential Functions: • Design, implement, and normalize DBA structures • Defines, creates, organizes, maintains logical, physical, and production DBA’s to include physical changes. • Prepare test data and tests program performance necessary to determine that program/system performs according to design specifications and end use requirements. • Develops and maintains system end user documentation necessary to ensure effective end user operations and IT support. 1. Establishes and maintains data security, including data backup/recovery and disaster planning. • Assigns user access levels as authorized by Senior Management. • Develop logical data models and program interfaces for applications systems. • Ensures that adequate and appropriate security features are installed in all Client computer systems necessary to protect the information resources of the Client from inappropriate access and dissemination. 2. Lead service support activities and initiatives • Initiate and lead support activities including problem analysis, technical evaluation, work estimates, and implementation services. • Coordinate support or project activities with all applicable constituents including customers using the systems, IT staff supporting the systems, vendors/third parties, and/or business managers. • Identify and lead, as assigned, resources and communications to facilitate work completion. 3. Provide technical guidance, training, and work direction to less experienced system engineers • Demonstrate technical proficiency in development and implementation of medium and complex systems and/or computing infrastructure through ability to guide others. • Strong learning competency and ability to teach others. • Advanced troubleshooting and problem solving capabilities 4. Assist other IT team members in understanding policies, operating procedures, and responsibilities • Mentor and train new IT team members to assist them in orientation to policies, procedures, and responsibilities. • Provide ongoing mentorship and support for questions, problems, and ideas. • Serve as an escalation point for system engineers to escalate problems and inquiries requiring further evaluation beyond the associated skill level. 5. Establish and maintain professional working relationships between IT and its customers and constituents. • Represent IT in project and/or business meeting and engagements. • Lead conference calls or visits with vendors/third parties. • Introduce new customers to IT services to assist in familiarizing them with appropriate systems, services, policies, and procedures. https://www.appone.com/MainInfoReq.asp?R_ID=466572&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=466572&B_ID=20&fid=1 Thu, 08 Apr 2010 00:00:00 GMT Essential Functions: 1. Lead development projects from inception/design through implementation. • Coordinate vendor relationships and commitments on project involvement/deliverables. • Design and implement systematic approaches and alternatives 2. Identify and document business requirements for new development projects and prepare detailed technical specifications from which programs or infrastructure can be built. • Conduct preliminary studies to define needs and determine feasibility • Confer with clients and analyze business/functional requirements • Develop procedures for moving program changes, enhancements, etc. into IT production processing. • Understand and relate business/functional requirements to application/infrastructure requirements. 3. Lead service support activities and initiatives • Initiate and lead support activities including problem analysis, technical evaluation, work estimates, and implementation services. • Coordinate support or project activities with all applicable constituents including customers using the systems, IT staff supporting the systems, vendors/third parties, and/or business managers. • Identify and lead, as assigned, resources and communications to facilitate work completion. 4. Provide technical guidance, training, and work direction to less experienced system engineers • Demonstrate technical proficiency in development and implementation of medium and complex systems and/or computing infrastructure through ability to guide others. • Strong learning competency and ability to teach others. • Advanced troubleshooting and problem solving capabilities 5. Assist other IT team members in understanding policies, operating procedures, and responsibilities • Mentor and train new IT team members to assist them in orientation to policies, procedures, and responsibilities. • Provide ongoing mentorship and support for questions, problems, and ideas. • Serve as an escalation point for system engineers to escalate problems and inquiries requiring further evaluation beyond the associated skill level. 6. Establish and maintain professional working relationships between IT and its customers and constituents. • Represent IT in project and/or business meeting and engagements. • Lead conference calls or visits with vendors/third parties. • Introduce new customers to IT services to assist in familiarizing them with appropriate systems, services, policies, and procedures. https://www.appone.com/MainInfoReq.asp?R_ID=470162&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=470162&B_ID=20&fid=1 Thu, 01 Apr 2010 00:00:00 GMT Job Summary: Works closely with customers, business analysts, and team members to understand business requirements that drive the analysis and design of quality technical solutions. These solutions must be aligned with business and IT strategies and comply with the organization’s architectural standards. Involved in the full systems life cycle and is responsible for designing, coding, testing, implementing, maintaining and supporting application software that is delivered on time and within budget. Makes recommendations towards the development of new code or reuse of existing code. Responsibilities may also include participation in component and data architecture design, performance monitoring, product evaluation and buy vs. build recommendations. Has experience in systems analysis, design and a solid understanding of development, quality assurance and integration methodologies. Essential Functions: • Defines architecture and design for enterprise applications. o Analyzes assigned specifications, planning, designing, and develops solutions, utilizing appropriate architecture processes. o Provides appropriate documentation for application design decisions, estimates assumptions and performance metrics. • Responsible for analysis and design of quality technical solutions o Analyzes, designs and builds component-based applications o Support systematic approaches to application integration. o Works on new and existing applications along with enhancements. o Performs hands-on coding, mentors junior developers and assists in architecting enterprise applications. o Serves as liaison to internal customers, research groups and various business support areas. • Lead projects from inception/design through implementation. o Solid project planning and management capabilities o Effective technical programming, analysis, and specification skills o Management skills in organizing and directing people and projects o Process and/or workflow planning and design skills • Lead service support activities and initiatives o Initiate and lead support activities including problem analysis, technical evaluation, work estimates, and implementation services. o Coordinate support or project activities with all applicable constituents including customers using the systems, IT staff supporting the systems, vendors/third parties, and/or business managers. o Identify and lead, as assigned, resources and communications to facilitate work completion. • Provide technical guidance, training, and work direction to less experienced system engineers o Demonstrate technical proficiency in development and implementation of medium and complex systems and/or computing infrastructure through ability to guide others. o Strong learning competency and ability to teach others. o Advanced troubleshooting and problem solving capabilities • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=470160&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=470160&B_ID=20&fid=1 Thu, 01 Apr 2010 00:00:00 GMT Job Summary: This position will work with team members, developers and department managers to develop, maintain, implement and execute a quality assurance process. The role is responsible to develop routine tests, and coordinate the testing efforts for all assigned applications and code base. Essential Functions: • Complete business analysis • Manage the requirements gathering process • Obtain and document business and system requirements • Document workflows • Provide requirements to development teams and participate in collaborative design sessions • Create and document test cases for all documented requirements • Manage and execute testing for all test cases: types include integration, certification, user acceptance, system, regression, and load tests. • Monitor, measure, and report metrics based on the results of all tests • Measure, Evaluate and test new or modified software programs and software development procedures used to verify that programs function according to user requirements and conform to established guidelines • Write, revise, and verify quality standards and test procedures for program design and product evaluation in order to economically and efficiently attain a high quality of software • Follow established quality assurance practices • Follow defined quality methods • Abide by quality controls and documentation procedures • Develop and maintain test plans, manual and automated test scripts for user interface, functionality, system and "ad-hoc testing" • Execute regression tests, functional tests and data tests • Report, track and determine priority of reported bugs promoting quality achievement and performance improvement • Maintain awareness of the business context of software • Ensure compliance with local, state, national and international standards and legislation • Define quality procedures in conjunction with operating staff • Collate and analyze performance data and charts against defined parameters • Ensure tests and procedures are properly understood, carried out and evaluated and that product modifications are investigated if necessary • Write technical and management systems reports • Monitor performance by gathering relevant data and producing statistical reports • Conduct tests on computer software programs to make sure the programs perform properly and are easy to use • Complete tests to determine weaknesses in software code • Review new or modified software, including documentation, diagram, and flow chart, to determine if a program will perform according to user requests and standards and conform to guidelines • Recommend program improvements or corrections to programmers • Identify program processing errors • Implement automated test programs to ascertain the validity of results, accuracy, reliability, and conformance to established standards • Identify differences between established standards and user applications and suggest modifications to conform to standards https://www.appone.com/MainInfoReq.asp?R_ID=470161&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=470161&B_ID=20&fid=1 Thu, 01 Apr 2010 00:00:00 GMT Job Summary: Provide leadership and direction for Statewide provider and ancillary contracting to facilitate optimal member access, successful business growth initiative and sound plan financial performance as it relates to unit pricing. Essential Functions: • Effectively manage day-to-day operations of the Contractors including but not limited to monthly co-visits for a full day and post visit mentoring to improve level of communication and service delivered • Travel within State a minimum of 75% of time and out of State if recruitment needs dictate • Implement Contracting Strategy and program and monitor key metrics for access and staff performance to ensure a high level of network adequacy, professionalism and staff performance • Responsible for execution from recruitment through provider onboarding to include new provider orientation • Function as a working manager, responsible for recruitment and contracting • Maintain high service levels of providers directly assigned • Support External Relations team as necessary when service needs dictate • Develop training, evaluation and development of Contractors and individual goals and accountabilities. • Participate in key corporate committees, subcommittees or workgroups as assigned • Develop market strategies related to Network Development by working closely with Marketing Department. This responsibility includes understanding, gathering and utilizing market intelligence data as it applies to Network Development. • Ensure network complies with all regulatory requirements as well as with all company-mandated policies and procedures. • Ensure that the appropriate policies, procedures and provider relations functions are in place to support the accreditation, HEDIS and audit processes. • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=460590&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=460590&B_ID=20&fid=1 Tue, 30 Mar 2010 00:00:00 GMT Job Summary: Responsible for knowledge of Facets and how that relates to each business area. Provider oversight of system configuration and perform review of setup upon completion. Manage tickets assignment, audit activities and Reimbursement and Benefit activities. Implement opportunities for process improvement that impact operations performance, quality, and/or profit. Ensure appropriate approvals, testing and controls are in place for all changes. Essential Functions: • Prioritize all work/request/activities. Escalate to management areas of significant resource contention along with recommendations for resolutions. • Track issues and their status to ensure proper follow-up and coordination of issues with business area. • Manage, organize and analyze data for presentation and approval to Reimbursement & Benefit committee. Maintain project plans/timelines and follow up with responsible parties to ensure appropriate implementation. • Conduct analysis, which compile information from various sources for members, claims and providers in support of Operation activities. • Audit and Manage system configuration of benefits/reimbursement and system configuration to ensure accuracy and internal controls are in place to minimize potential fraud and abuse and any business issues. • Play a consultative role with business owners around benefits and reimbursement related to claims, etc. • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=461030&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=461030&B_ID=20&fid=1 Wed, 03 Mar 2010 00:00:00 GMT Job Summary: Manage CareSource Advantage Sales (SNP) execution. Drive and achieve health plan Medicaid enrollment/ growth goals in Michigan, primary interface between IT and all markets for Customer Relationship Management (CRM) lead management and reporting, manage effective execution of telephonic sales activities all products/all markets. Essential Functions: Travel, primarily in the State of Michigan, is required to perform the essential functions of this job. Manage CareSource Advantage Sales execution and Medicaid enrollment growth in Michigan • Rigorous, high frequency coaching/development of Sales and Marketing Representatives in account management and prospect pipeline management environments to achieve sales and enrollment goals • Work with Provider Relations to develop marketing opportunities within health centers and physician offices • Develop new forums to market and educate potential enrollees about the benefit of enrolling in CareSource. • Maintain working knowledge of plan benefit and program changes. • Coordinate weekly and monthly schedules of regional marketing staff to assure maximum coverage of marketing venues. • Monitor the activity of Community Sales and Marketing Representatives and assist with development of new marketing venues • Provide ongoing input and feedback to staff about marketing presentation effectiveness, and sales and marketing techniques. • Perform any other job related instructions as requested, with reasonable accommodation. • Assure proper use of CRM • Develop and execute major aggregate sales opportunities for SNP facilitated by detailed project planning • Work closely with Marketing to gain support needed to assure successful sales execution plans • Responsible for managing a detailed enrollment forecasting model • Partner with Provider Relations to assure targeted SNP network growth goals are met Primary interface between IT and all markets/all products for CRM lead management and reporting. • Play a key role in the system implementation • Assist all Sales Directors/all markets to assure the system is being used effectively with a focus on proper lead management • Assure that the markets are getting and using reports appropriately to manage the business • Represent the markets with IT on any system related issues Manage all prospect telephonic activity for all markets/products • Assure proper workflows are in place, technology is used appropriately and reporting is in place to achieve results on all inbound prospect calls coming into CareSource • Build and manage the execution of outbound campaigns https://www.appone.com/MainInfoReq.asp?R_ID=461057&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=461057&B_ID=20&fid=1 Tue, 02 Mar 2010 00:00:00 GMT Job Summary: The Community Sales and Marketing Representative will drive and achieve health plan enrollment/growth goals by managing business/community relationships for both the Medicare and Medicaid product lines within an assigned territory and consistent with state and federal regulations for both programs. Territory: SW Michigan; Counties of Berrien, Van Buren, Cass Essential Functions: • The Community Sales and Marketing Representative is responsible for educating eligible consumers and the community about the CareSource Medicare/Medicaid product lines; generating enrollment leads and referrals; supporting enrollment of Medicare eligible consumers into the CareSource Medicare Advantage plan; facilitating enrollment growth in the Medicaid product; and managing CareSource’s engagement with community stakeholders and organizations focused on services to a shared client base. • Work under the direction of the Director of Marketing/Sales to drive and achieve marketing goals by leading or advancing the marketing cycle. • Contribute to the development of a viable marketing plan for the designated territory. • Serve as a subject matter expect on CareSource Medicaid/Medicare plans and product lines. • Serve as a liaison for the health plan in designated communities via community/individual education opportunities. • Develop new forums to market and educate eligible consumers and the community about CareSource products. • Conduct presentations, marketing activities and other informational events in accordance with current approved communication and marketing programs and state/federal regulations. • Participate in planning and implementation of community outreach strategies and programs in conjunction with Quality Improvement and Provider Relations staff. • Travel throughout region to provide education about the organization to promote enrollment. • Execute basic administrative duties as defined by the Director of Marketing/Sales, including updates and maintenance of appropriate reporting/database systems (funnel management, customer information, territory planning, etc.) • Maintain working knowledge of plan benefit, program changes and industry insights. • Ensure compliance and quality of marketing and outreach process components, adhering to all applicable state and federal regulatory requirements. • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=461061&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=461061&B_ID=20&fid=1 Tue, 02 Mar 2010 00:00:00 GMT Job Summary: Provide leadership for a comprehensive corporate compliance program to ensure organizational compliance with federal and state regulatory and accreditation requirements to include relationship management and program advocacy with CMS and state regulatory agencies, incorporation of new requirements into plan operations and monitoring plan performance against requirements. Serve as the CareSource HIPAA Privacy Compliance Officer. Essential Functions: • Provide leadership for corporate compliance program, maintaining and implementing the corporate compliance plan. • Lead relationship management with state and federal regulators including advocacy on program requirements. • Develop and implement an annual compliance monitoring program, integrating with the overall corporate audit plan. • Coordinate organizational participation in federal and state regulatory audits and site visits. • Drive the focus and management of plan initiatives and performance monitoring to obtain success in regulatory incentive programs. • Ensure staff and leadership training on the regulatory environment, programs and requirements. • Coordinate all non-financial regulatory filings including annual required submissions and those to support new business development. • Provide support to the organization in assessing and incorporating new program requirements into operations and the oversight of delegated vendors. • Ensure a comprehensive HIPAA Privacy compliance program is in place to meet federal, state and accreditation requirements. • Support the Corporate Integrity and Compliance Committee and prepare Board of Director reports as appropriate. • Investigate reported violations of regulatory requirements and the development and enforcement of appropriate corrective actions. • Provide management and oversight of professional staff • Perform any other job related duties as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=460857&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=460857&B_ID=20&fid=1 Mon, 15 Feb 2010 00:00:00 GMT Review, track and trend QI issues and report all issues to Senior Management. Retrieve and perform analysis on data and medical records; review records and forward them to state auditors for EQR studies and HEDIS audits. Execute quality improvement initiatives as well as facilitate URAC work teams. https://www.appone.com/MainInfoReq.asp?R_ID=460004&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=460004&B_ID=20&fid=1 Thu, 11 Feb 2010 00:00:00 GMT Job Summary: The Director of Informatics is primarily responsible for providing strategic direction to the organization for complex analytic efforts and findings. The Director will oversee the operation of the department to ensure it aligns with the business objectives of the company. The Director is also responsible for creating, scoping, planning, prioritizing and management of all informatics projects and staff. This person must work with key business units to establish and meet their analytic needs. The Director will also work as a high-level analyst for Senior Management of the organization. In this capacity the Director will explore, research and validate various ideas for studies that could identify reductions in health care costs or delivery of higher quality services to our members. This includes the extensive use of predictive techniques to forecast trends and patterns of care. These ideas will then result in informatics team efforts to explore the validity of the concept. This Director, in working with the VP, DSI, locate opportunities to create visibility for CareSource though public forums or publication regarding the delivery of high quality, insightful analytics that reveal unique insights to our membership or the healthcare delivery system where CareSource conducts business. Essential Functions: • Responsible for directing the creation, scoping, planning, prioritizing and managing of Informatics. This includes working with key business owners to establish and meet their analytic needs or the analytic needs of the organization. • Serve as informatics consultant for members of the senior and executive CareSource management team. • Responsible for the direction, coaching and management of the Informatics team as they conduct in-depth analysis such as provider practice patterns, examination of complex data relationships, and use of statistical techniques to measure impact of various actions/results. • Serve as a DSI senior management liaison on analytic needs of the organization including key operational and management committees. • Responsible for the determination of appropriate predictive solutions throughout the organization and, as needed, assist the Director, BI Services with the deployment of those solutions into the organizations workflow. • Conceive, establish and direct the development of various outcome/predictive/analytic studies that establish CareSource as a leader in analytics regarding the healthcare status, needs or delivery results of our membership. These efforts would identify trends and variances and identify in-depth cause-effect relationship between seemingly unrelated components, culminating in some public publication and/or presentation of the findings. • Working with the Director, BI Services, drive the creation of unique graphics that effectively describe, explore and summarize analysis for communication to appropriate parties. • Assist VP, Decision Support & informatics with https://www.appone.com/MainInfoReq.asp?R_ID=458868&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=458868&B_ID=20&fid=1 Wed, 10 Feb 2010 00:00:00 GMT Job Summary: Lead a small team of developers to deliver enhancements to and manage defects of assigned application development. Work closely with customers, business partners, project managers, and team members to understand business requirements that drive the analysis and design of quality solutions. These solutions must be aligned with business and IT strategies and comply with the organization’s architectural standards. Involved in the full systems’ life cycle and is responsible for designing, coding, testing, implementing, maintaining and supporting application software that is delivered on time and within budget. Essential Functions: • Clarify and drive team goals on a technical level making sure that the solutions proposed and designed are in line with the department’s vision • Lead component and data architecture design, performance monitoring, product evaluation and buy vs. build recommendations • Mentor other developers • Build and drive application strategies according to depart, IT, and company strategies • Assist manager with resource planning and release planning • Review and approve designs and code • Defines architecture and design for enterprise applications o Analyzes assigned specifications, planning, designing, and develops solutions, utilizing appropriate architecture processes o Provides appropriate documentation for application design decisions, estimates assumptions and performance metrics • Responsible for analysis and design of quality technical solutions o Recommend the development of new code or reuse of existing code o Analyzes, designs and builds component-based applications o Support systematic approaches to application integration o Works on new and existing applications along with enhancements. o Performs hands-on coding, mentors junior developers and assists in architecting enterprise applications o Serves as liaison to internal customers, research groups and various business support areas • Lead projects from inception/design through implementation o Solid project planning and management capabilities o Effective technical programming, analysis, and specification skills o Management skills in organizing and directing people and projects o Process and/or workflow planning and design skills • Lead service support activities and initiatives o Initiate and lead support activities including problem analysis, technical evaluation, work estimates, and implementation services. o Coordinate support or project activities with all applicable constituents including customers using the systems, IT staff supporting the systems, vendors/third parties, and/or business managers o Identify and lead, as assigned, resources and communications to facilitate work completion • Provide technical guidance, training, and work direction to less experienced system engineers o Demonstrate technical proficiency in development and implementation of medium and complex systems and/or computing infrastructu https://www.appone.com/MainInfoReq.asp?R_ID=454712&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=454712&B_ID=20&fid=1 Fri, 29 Jan 2010 00:00:00 GMT Job Summary: Responsible for utilization review and discharge planning activities for members enrolled with a CareSource Management Group (CareSource) line of business, monitoring the appropriate delivery of health care services in a cost effective manner. Maintain knowledge of State and Federal regulations governing CareSource, State Contracts and Provider Agreement, benefits and URAC Standards. Essential Functions: • Prospective, retrospective and concurrent review of inpatient admissions, outpatient procedures, homecare services and durable medical equipment. • Coordinate care and facilitate discharge to an appropriate level of care in a timely and cost-effective manner. • Identify and refer quality issues to Quality Improvement. • Identify and refer appropriate members for Case Management. • Document and communicate with CareSource and Provider Case Managers and Discharge Planners to establish discharge planning needs and coordinate care. • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=457243&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=457243&B_ID=20&fid=1 Sun, 24 Jan 2010 00:00:00 GMT Job Summary: The Storage Architect will be responsible for the design and administration of the storage area network including: the storage arrays, the fibre channel switches, the network attached storage, and the content addressed storage. Essential Functions: • Plan, Present, Design and Architect current, interim and future Storage Technologies growth & upgrade cycles using cost effective methodologies working with multiple teams (Storage, DBA, Servers, Networks, and Applications) • Plan and maintain SAN Disaster Recovery/Business Continuity components and procedures • Work with the CIO and IT Managers to drive multiple storage projects within different time lines • Mentor Storage engineers • Perform any other job related instructions as requested, with reasonable accommodation. https://www.appone.com/MainInfoReq.asp?R_ID=453251&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=453251&B_ID=20&fid=1 Thu, 21 Jan 2010 00:00:00 GMT Job Summary: Responsible for utilization review and discharge planning activities for members enrolled with a CareSource Management Group (CareSource) line of business, monitoring the appropriate delivery of health care services in a cost effective manner. Maintain knowledge of State and Federal regulations governing CareSource, State Contracts and Provider Agreement, benefits and URAC Standards. Essential Functions: • Prospective, retrospective and concurrent review of inpatient admissions, outpatient procedures, homecare services and durable medical equipment. • Coordinate care and facilitate discharge to an appropriate level of care in a timely and cost-effective manner. • Identify and refer quality issues to Quality Improvement. • Identify and refer appropriate members for Case Management. • Document and communicate with CareSource and Provider Case Managers and Discharge Planners to establish discharge planning needs and coordinate care. • Perform any other job related instructions as requested, with reasonable accommodation. • Provide direction to non-clinical medical management staff. • RN’s - Provide direction to and assist with oversight of LPN, LISW medical management staff. https://www.appone.com/MainInfoReq.asp?R_ID=452174&B_ID=20&fid=1 https://www.appone.com/MainInfoReq.asp?R_ID=452174&B_ID=20&fid=1 Fri, 11 Dec 2009 00:00:00 GMT