Supports the direction and coordination of medical affairs to include quality management, utilization management, case management, and preventive health services. Provides direct assistance to the Medical Director. Requires a medical degree from an accredited medical school and a license to practice. Experience in a managed health plan is typically desired.: Reviews and makes determinations on all questionable physician review decisions. Assists in the development of clinical practice guidelines or case management guidelines. Participates in the review and approval of inter-rater reliability monitoring. Provides medical input into the development of preventive health, quality improvement, and utilization management activities. Assists with the analysis of provider profiles to identify areas for improvement. Serves as an interface in professional or institutional matters between the plan and its providers. May conduct provider profile consultation visits.
|
Assists Pharmacists in filling orders, checking prices, and stocking shelves in a retail pharmacy establishment. Serves customers at a pharmacy counter and processes purchases. Typically requires on-the-job training.: Takes customer orders, delivers customer orders, computes charges, handles payment, and enters data in computer. Cleans equipment and sterilizes glassware according to prescribed methods. Types and files reports and completes forms as directed. Assists in receiving and storing supplies, stocking shelves, checking prices, and maintaining inventory.
|
Provides technical and clerical assistance to facilitate effective and efficient operation of the provider credentialing function.: Coordinates and performs enrollment of assigned providers and physicians in appropriate health plans to ensure satisfaction of the health plan requirement for acceptance. Reviews and processes provider applications and determines eligibility by applying NCQA, JCAHO and URAC standards as related to the network. Performs primary source verification for initial and re-credentialing of assigned providers utilizing NCQA and other federal and state regulatory requirements. Analyzes and resolves basic provider issues relative to credentialing, enrollment, billing and payers. Communicates with providers regarding credentialing status and information.
Creates and maintains participating provider or practitioner credentialing files. Reviews and analyzes provider file changes. Creates practitioner profiles for re-credentialed practitioners. Prepares and sends application packets to participating providers and facility applicants, requesting the return of basic credentialing information. Reviews applications for completeness and assists the applicant in completing the application. Prepares routine credentialing reports. This position typically requires a experience sufficient to provide a working knowledge of NCQA and JCAHO.
|
Engages in actuarial sciences, statistics, principles of finance, and business to problems in life, health, social, and casualty insurance, annuities, and pensions. The Associate level performs more complex actuarial studies and has demonstrated greater professional competence by completion of additional examinations. The Associate level generally requires five to seven years of previous experience at the Enrolled actuary level and completion of a series of examinations required for the professional designation of an Associate.: Determines mortality, accident, sickness, disability, and retirement rates; constructs probability tables regarding fire, natural disasters, and unemployment, based on analysis of statistical data and other pertinent information. Designs or reviews insurance and pension plans and calculates premiums. Ascertains premium rates required and cash reserves and liabilities necessary to ensure payment of future benefits. Determines equitable basis for distributing surplus earnings under participating insurance and annuity contracts in mutual companies. Forecasts financial outcomes using pricing, analysis, and risk assessment.
|
Provides general legal support and advice for a corporation, as directed by the General Counsel, through timely responses to inquiries and requests. Negotiates agreements with key strategic partners. Serves as a subject matter expert to the Law Department, Compliance, Government Relations, and other business units.: Negotiates contracts and performs legal analysis and drafting. Advises and counsels senior business clients in connection with sales practice issues and other issues. Reviews applicable statutes and regulations. Assists with the preparation of responses to various regulatory inquiries. Supervises and manages regulatory examinations conducted by external agencies. Prepares and reviews registration statements of business development companies. May manage and obtain licenses in various states. May collaborate with business partners on healthcare insurance issues and healthcare regulatory issues. May prepare and report corporate information to the SEC. May collaborate with a team of legal professionals.
|
Develops and maintains clinical software applications. Designs, produces, and analyzes health data reports. This position is an entry-level analyst position but typically requires a college degree and familiarity with computer information systems.: Analyzes, develops, and maintains computer applications, procedures, and other systems that satisfy the needs of the clinical user departments. Assists in developing design work, including testing and documentation. Designs, produces, and analyzes specific health care reports. Reviews, evaluates, and implements requests from clinical user departments. Assists in monitoring computer applications to ensure proper use and security. Analyzes problems, determines causes, and initiates corrective action. Assists in the development of clear and concise documentation and instruction manuals. Coordinates and installs new software applications with user departments. Maintains a high level of interaction with all clinical areas to continually enhance and improve patient care.
|
Administers the installation of assigned accounts under general direction including, but not limited to, structure and billing setup, eligibility collection, database loading, and preparation of plan materials, such as administrative documents and customer education materials.: Provides support to assigned accounts by responding to inquiries and resolving issues of concern. May provide guidance or expertise to less experienced representatives.
|
Performs administrative, supervisory, and complex clerical work. Interacts with all levels of executive management, support staff, clients, etc., with strictest confidence, professionalism, and respect. Exercises judgment and initiative in answering verbal and written communications with internal and external contacts and in interpreting departmental policies, rules, and regulations. Assists in administration of department policies and procedures. Establishes and manages a variety of administrative processes including requisitions, expense reconciliation, and contact database management.: Assists in the preparation and editing of presentations. Represents the department to internal and external individuals and groups, which includes making decisions that affect the department. Coordinates processing of personnel actions, including confidential information, consistent with organization policy and procedures. Manages active calendars by organizing, coordinating, and making arrangements for meetings and conferences, including scheduling rooms, food service, travel, and housing for internal and external contacts. Compiles and maintains records of business transactions and office activities of an organization. Operates office machines, such as computer, fax machines, adding machines, and duplicating machines. Coordinates operation and maintenance of all office equipment and recommends lease or purchase of office equipment. Opens and routes incoming mail and responds to telephone messages, e-mail, and correspondence. Assists other executives/administrative assistants with project-based work. Assists with a variety of special projects as requested. May take dictation. May greet and assist visitors. May prepare payroll, computing wages, taxes, premiums, commissions, and payments. May prepare, issue, and send out receipts, bills, policies, invoices, statements, and checks. May keep books. May purchase and maintain office supplies.
|
Receives cash, personal check, or charge or debit card for payment of food, rent, property, deposits, fees, accounts receivable, or other goods and services. Operates cash register, scanners, and computers to itemize and total customer's purchases.: Records prices, subtotals taxable items, and totals purchases on cash register. Collects cash, check, or charge payment from customer and makes change for cash transactions. Checks identification when required by transaction. Checks and verifies to note price changes. Counts money in cash drawer at beginning and end of work shift. Ensures accuracy of collection and disbursement of funds. May open and close cashier window. May record daily transaction amounts from cash register to balance cash drawer. May cash checks. May use electronic scanner to record price. May collect and issue refunds.
|
Coordinates and assists with activities of projects to ensure that goals or objectives of projects are accomplished within prescribed time frame and funding parameters. Manages daily operational aspects of a project and scope.: Assists with the planning, execution, and finalizing of projects according to strict deadlines and within budget. Participates in the definition of project objectives and monitors quality control. Coordinates the acquisition of resources and the efforts of team members, contractors, and consultants. Creates and executes project work plans and revises as appropriate to meet changing needs, requirements, and project team workload. Maintains data and generates reports used to plan and implement project activities. Communicates information regarding work plans, schedules, and related requirements. Creates documentation on work flow and processes and tracks projects using project management tools. Ensures that projects are progressing on schedule and team members are staying on task. Resolves and/or escalates risks and issues. Identifies and suggests opportunities for improvement. Collaborates with other project management personnel on various coordination efforts. Schedules and arranges meetings, attending and recording major activities at the meetings.
|
