Member Relations Compliance Rep - JHP

Number of Positions In Requisition

1



Job Details

This position reports to the Manager, Member Relations. Responsibilities include but are not limited to the monitoring of operational compliance requirements. This role requires mastering and demonstrating skills and concepts within all lines of business supported by Member Relations (currently Medicaid, Medicare, CHIP PPO, ACA) in reference to enrollment, appeals
and grievances, Complaint Tracking Module, claims, billing, marketing, etc. The specific goal of this position is to effectively monitor and oversee operational measures for both internal member relations teams and affiliated vendors. This position also includes the management of CMS, DHS and OOC communication and assisting with audit objectives. Individual must be able to
operate independently.

Hours: Monday thru Friday, 9am -5:30 pm.

Job Description

• Serve as a point of contact for all internal departments and vendor for CMS, DHS, and OOC communications including HPMS issued guidance, and other relevant regulatory and sub-regulatory guidance.

• Review of CMS, DHS, OOC and NCQA guidance and how it applies to Member Relations and related first tier downstream entities.

• Development of related processes and policies.

• Monitoring and documentation of operational compliance components. • Effectively communicate with various internal management teams to ensure compliance with contractual/regulatory requirements.

• Act as a representative of Jefferson Health Plans at internal and external meetings/workgroups, etc., as required or requested.

• Educate staff on compliance updates and how it applies to day to day operations for areas of responsibility.

• Assist with data collection and organization for Medicare, CHIP, NCQA and Medicaid audits, internal - external.

• Maintain records to demonstrate timely completion of all internal requests. • Assist management in reviewing, clarifying and disseminating CMS, DHS, OOC and NCQA guidance to appropriate Jefferson Health Plans Member Relations staff and associated vendors.

• Report on trends and issues that impact the Member Relations Department staff.

• Participate in appropriate staff meetings. Responsible for the documentation and creation of operating procedures.

• Identify Training gaps/needs. Provide recommendations and feedback. • Call listening to monitor for compliance and standard process. Act as an interdepartmental liaison.

• Coordinate cross-functional and interdepartmental initiatives. Facilitate training sessions and vendor oversight meetings.

• Mock audit activity as needed. Test calls- including the monitoring/documentation of quality results.

• Monitoring of call center performance. Track performance outcomes and improvement activities.

• May perform other duties as assigned.

Education - Preferred: • Bachelor’s Degree or equivalent work experience.

Experience - Required: 2 years of Medicare and Medicaid operational experience.

Knowledge, Skills and Abilities - Required: Excellent written and verbal communication skills. • Ability to manage multiple tasks and adhere to deadlines. • Ability to work independent of direct supervision, but also must be able to meet and exceed deadlines for close turnaround timeframes. • Proficiency in Departmental Information Systems including DPW, Member Health Information System and Pharmacy Systems. • Must possess ability to provide continual updates to management on all issues, bringing those with potential impact to the attention of management immediately. • Ability to maintain open, amicable communication with government entities, and Health Partners management, in an effort to ensure development of a “partnership” relationship.

Knowledge, Skills and Abilities - Preferred: • Preferred demonstrated experience across multiple Medicare, Medicaid, OOC and NCQA disciplines i.e. CTM, call center, grievances, and monitoring. • Bilingual a plus, but not necessary.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Health Partners Plans, Inc.

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.    

Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. 

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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