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Directs the Medicare Membership function in a health plan.: Plans and directs operations within the Medicare Membership department to provide explanation of benefits and response to Medicare members’ questions and complaints. Plans, implements and continuously evaluates the member service program to enhance the effective use of services and to improve customer satisfaction. Instructs departmental staff on proper member service procedures and monitors service levels. Researches and evaluates complaint reports to detect patterns, formulate solutions and report needed actions to appropriate individuals, departments or committees. Works with Medicare members on complex issues to offer mutually acceptable alternatives to problems and complaints. Responsible for hiring, developing and managing a qualified staff concerned with providing member service to Medicare members of the health plan. Prepares and manages the departmental budget. Monitors departmental statistics, reports results and develops action plans that address deficits. Participates on various committees to formulate actions to proactively address member and provider needs. Prepares and presents management reports that show departmental activities as well as specific problems identified and solutions. Develops and implements policies and procedures related to customer service. This position typically requires a Bachelor’s degree with five years of health plan experience in a customer service call center.

Medicare Member Services Director

Plans and directs Medicare operations including claims, information systems, purchasing, and facilities to ensure processing of the health plan's Medicare claims. Ensures that all operations meet the plan's objectives and requirements relative to Medicare members and providers. Directs the implementation and ongoing maintenance of claims handling systems, policies, and procedures. Typically requires a college degree and five or more years of Medicare claims management experience.: Monitors departmental operations to ensure compliance with regulatory agencies as well as contractual obligations. Performs regular data analysis of claims payment reports to identify variances so that areas of focus may be identified and resources may be appropriately deployed. Prepares and manages the departmental budget and manages expenses. Hires, develops, and motivates a qualified claims processing staff. Provides support on complex claims issues.

Medicare Member Services Manager

Manages Medicare Service Representatives within the Medicare Membership function in a health plan. Monitors departmental statistics, reports results and develops action plans that address deficits. This position typically requires five years of health plan experience in a customer service call center.: Manages Medicare Service Representatives within the Medicare Membership function in a health plan. Implements policies and procedures within the Medicare Membership department to ensure provision of accurate explanation of benefits and response to Medicare members’ questions and complaints. Plans, implements and continuously evaluates the Medicare member service program to enhance the effective use of services and to improve customer satisfaction. Instructs departmental staff on proper member service procedures and monitors service levels. Researches and evaluates complaint reports to detect patterns, formulate solutions and report needed actions to appropriate individuals, departments or committees. Works with Medicare members on complex issues to offer mutually acceptable alternatives to problems and complaints. Responsible for hiring, developing and managing a qualified staff concerned with providing member service to Medicare members of the health plan. Assists in the preparation and management of the departmental budget. Monitors departmental statistics, reports results and develops action plans that address deficits. This position typically requires five years of health plan experience in a customer service call center.

Medicare Marketing Manager

Manages a diversified Medicare marketing program to include development and implementation of various promotional ideas and activities for health services.: Develops and oversees implementation of promotional programs to publicize and promote various Medicare activities, events and services. Oversees and coordinates activities necessary to build and maintain strong, strategic relationships with clients by proactively identifying and meeting service delivery needs. Develops and implements methods for increasing participation in promotional programs. Analyzes, plans, and coordinates sales programs that market services and programs. Conducts demographic and other marketing studies to identify trends to maximize effectiveness of marketing efforts. Researches targeted markets and evaluates marketing strategies to identify potential consumers of services. Recommends appropriate policies regarding pricing, promotion, product and market evaluations and marketing plans. Prepares reports and analyses showing progress or adverse trends and presents appropriate recommendations or conclusions to management. Responsible for hiring, developing and managing a qualified staff concerned with Medicare marketing services and managing accounts. This position typically requires a college degree with four years of health service marketing experience. May assist in various special projects such as cost feasibility studies for proposed or ongoing programs.

Medicare Nurse Case Manager

Plans, directs, implements, and evaluates appropriate healthcare services for Medicare patients in conjunction with Physician's treatment plan to ensure that cost effective, quality care is provided. Typically requires licensure as a Registered Nurse with three years of relevant nursing and medical case management experience. Certification as a Case Manager or professional certification in a clinical specialty may also be required.: Coordinates cases that normally include prospective and retrospective review and prior authorization, determining the appropriate level of care and utilization of services, concurrent review, retrospective review, developing discharge plans, and ensuring quality cost effectiveness. Develops a plan of care for Medicare patients from admission to discharge. Monitors patient progress toward desired outcomes through assessments and evaluations. Develops and administers education and prevention programs for Medicare patients. Analyzes referred cases for potential case management interventions. Evaluates the effectiveness of alternate care services and ensures that cost effective, quality care is maintained to meet case management objectives. Determines if proposed medical treatment plans meet contract provisions. May arrange referrals, consultations, therapeutic services, and confer with other specialists on course of care and treatment. May negotiate fees with providers of medical care, agencies, and outside vendors to achieve maximum cost effectiveness.

Medicare Coordinator

Reviews Medicare inpatients and assists medical staff and fiscal services to assure that a satisfactory system is maintained. Monitors the organization's potential financial risk for Medicare patients, and assesses the financial status of Medicare patients. Ensures the accurate selection of the primary diagnosis and procedure and any complicating or pre-existing conditions in accordance with Medicare definitions by reviewing Medicare inpatients' records. : Identifies cases that may qualify for outpatient status, and gathers data for appeals to the Medicare program. Ensures adequate system is maintained to guarantee appropriate Medicare reimbursement in order to maintain a high level of quality patient assistance while staying within the DRG System financial limits. Identifies trends and problem areas by reviewing facility and physician case-mix financial data.

Medicare Patient Representative

Manages Medicare patient accounts, ensuring complete and accurate billing. Interacts directly with patients on billing related matters. Interviews patients and responsible parties to obtain and record personal, family, and financial data.: Analyzes patients' ability to pay and determines appropriate fees, possibly using a sliding scale. Collaborates with the business office, clinical practice teams, and hospital systems to identify appropriate charges and documentation. Verifies Medicare eligibility and prepares input documents for billing. Ensures patient accounts meet Medicare standards and billing requirements. Informs patients of steps to be taken to eliminate indebtedness and the financial impact of various alternatives. Posts credits and debits to accounts and contacts patients with delinquent accounts to arrange payments. Serves as liaison to Patient Financial Services. Communicates with external government payers and employers. May answer telephones in a centralized call center.

Medicare Claims Clerk

Processes and codes routine Medicare claims for payment and provides general support to the Medicare claims staff. Reviews and codes routine claims under direct supervision. This is an entry-level position and typically does not require previous claims processing experience.: Compares claim application and/or provider statement with plan file and other records to evaluate completeness and validity of claim. Requests information from internal or outside sources to ascertain completeness and validity of claim including coordination of benefits information. Routes claims requiring additional information. Researches claim as needed. Communicates with claimants to correct errors or omissions on claim forms.

Medicare Member Services Representative

Communicates effectively with providers and Medicare members of the health plan, answering inquiries about Medicare member eligibility, plan benefits, and claims status. Provides customer service to Medicare plan members by answering benefit questions, resolving issues, and educating callers. Typically has more than two years of experience in customer service.: Receives inquiries from Medicare members via the Internet, telephone, and in writing regarding covered benefits. Provides assistance in resolving problems such as finding physicians, arranging transportation, ordering identification cards, filing appeals, resolving billing errors, and accessing payment. Clarifies benefit changes or exclusions. Maintains records of all contacts and results. Provides claim status, payment amounts, and/or denials for processed claims. Reports successive claims payment issues or member issues to management for appropriate intervention. Assists providers with standard electronic claims submission questions and works with providers to resolve problems in filing electronic claims. Mails out provider directories and new member packets. Assists providers and members in accessing information via the organization's online services directory.

Medicare Marketing Representative

Supports a broad range of marketing activities and promotes sales and creates goodwill for the plan's Medicare products or services among customers or prospects. Makes forecasts on anticipated market sales. This is a professional level non-supervisory position; the level of responsibilities normally require a degree in sales or marketing.: Submits reports of marketing and sales activity and maintains records. Supports advertising programs and communication programs designed to promote products or services. Plans own work schedules within limits assigned. Remains informed of changes that might affect Medicare product sales or services, including contract procedures and product prices.

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