Massachusetts
Director, Risk Adjustment
Grievance, Denials and Appeals Coordinator
Manager, Pharmacy
Clinical Trainer
Behavioral Health Specialist
Nurse Care Manager
Manager, Credentialing
Community Resource Coordinator
Quality Specialist, Accreditation
Actuary
Director, Risk Adjustment
The Director, Risk Adjustment is responsible for maintaining current practices in revenue accuracy and risk adjustment as well as developing new and innovative initiatives.
Responsibilities include, but are not limited to:
- Develop and implement new strategies for improving revenue accuracy
- Monitor current risk adjustment practices and capitalize on improvement opportunities
- Work with analysts to report on productivity and impact of each initiative
- Implement and optimize healthcare system, Voyager, for analytics
- Manage staff, including the Risk Adjustment Coding Manager who oversees coders responsible for retrospective review
Candidate will have an understanding of managed care. 3-5 years in a managed Medicare/Medicaid preferred. Knowledge of CMS risk adjustment a plus. Strong communication and documentation skills. Proven ability to think through creative solutions to business problems.
Grievance, Denials and Appeals Coordinator
The Grievance, Denials and Appeals Coordinator will be responsible for coordinating grievance and appeal activity within the Plan and in collaboration with external agencies, as required - ensuring compliance with Federal, New York and Massachusetts State regulations and accrediting standards.
Responsibilities include, but are not limited to:
- Investigate all grievances and appeals and coordinate input from other departments, interacting with external governing agencies and vendors when necessary.
- Track and trend all grievances and appeals, report findings and aggregate data for committee review and submit recommendations for Plan consideration.
- Provide oversight of delegates’ appeals and grievances activity
- Play a role in helping define and document the process for appeals and grievance management within the organization
Candidate must have a Bachelors degree and at least 5 years experience managing and processing grievances, denials and appeals in the managed care environment. S/he must be able to interpret and apply CMS and State regulations appropriately and have experience managing the grievance, denials and appeals processes in an NCQA environment. Must be able to communicate clearly and effectively with both internal and external stakeholders and possess excellent verbal and written communication skills. Must possess excellent organizational skills, the ability to meet time-sensitive deadlines and the ability to multi-task on a consistent basis.
Manager, Pharmacy
Manages day-to-day corporate pharmacy operations and leads efforts in Massachusetts both clinically and with retail pharmacy relationships. He/She will be the sole Pharmacist on the regional team, but there is collegial support of other plan Pharmacists.
Responsibilities include both clinical and management components in a managed care pharmacy department. Responsibilities include but are not limited to:
- Fulfills all functions of the Pharmacy Director when Director is not available
- Provides a leadership role for the department in cooperation with the Director
- Direct supervision of Pharmacy Project Coordinators and students involved in the day-to-day operations of the department
- Responsible for developing pharmacy network relationships for the Massachusetts Office
- Assists in developing other relationships with clinical providers to SWH members
- Responsible for the pharmacy clinical support in the Massachusetts Office
- Attends meetings as required (MAC, P&T, QMC, Rounds)
- Supports corporate programs and initiatives relating to pharmacy
- Works directly with the plans PBM
- Understands and manages benefit issues with regards to pharmacy in compliance with CMS requirements
- Produces PBM reports and reviews analytics to propose new interventions and document successes
Minimum of 5 years experience as a Pharmacist; minimum of 2 years in management. BS Pharmacy with MA license (or eligible for reciprocity). Additional NY license preferred. Advanced degree MBA or PharmD preferred. Managed care residency and Medicare and Medicaid experience preferred. Strong knowledge of health care contracts in MA preferred.
Clinical Trainer
The Clinical Trainer will provide orientation and assist with ongoing quality assessments for the department in close collaboration with the Clinical Managers.
Responsibilities include, but are not limited to:
- Provide training and support to Care Management staff with a focus on technology
- Participate in training staff in application of clinical criteria, measure and monitor consistency, including oversight of inter-rater reliability of standard clinical criteria
- Participate in training, developing and implementing policy and procedures
- Work with other departments to develop and oversee the use of tools for self-directed learning and staff development
- Participates in quality initiatives in collaboration with Clinical Managers
- Assists department in compilation of data and reporting
- Works with Clinical Manager to identify and address learning needs of the department
MA Registered RN with valid driver’s license and reliable transportation. 2-3 years technology training experience or related staff training. 3-5 years working with geriatric population or equivalent relevant experience. Working knowledge of Medicare/Medicaid programs and understanding of state reporting and assessment requirements. Knowledge of current health care market and best practices. Excellent computer and communication skills. Strong mentoring skills and the demonstrated capacity to work within a team structure.
Behavioral Health Specialist
In collaboration with the Clinical team, the Behavioral Health Specialist will oversee the administration of SWH’s behavioral health benefits and serve as a resource for staff. This will include working with the SWH behavioral health vendor, providing guidance on programmatic needs, identifying trends, and optimizing access to care for members in the community and in long-term care.
Responsibilities include, but are not limited to:
- Work with behavioral health vendor to monitor and optimize access to behavioral health services for SWH members
- Collaborate with clinical and client services’ teams to manage members with complex behavioral health needs
- Develop programs which meet the unique needs of English/non-English speakers
- Serve as a resource for staff on geriatric behavioral health issues
- Participate in clinical rounds
- Interact with members to facilitate appropriate care linkages and interact with SWH Physicians around behavioral health management of members
- Develop outcome measurements
Advanced degree in related field. Minimum of 10 years working in geriatric behavioral health. Proven program development skills and vendor management experience. Experience with diverse populations. Valid MA driver’s license and reliable transportation for 40% travel within SWH local service area.
Nurse Care Manager
Nurses work independently within a supportive organization of professional colleagues. SWH cares for elders through the care continuum. In collaboration with the elder’s primary care physician and an interdisciplinary team, the Nurse Care Manager develops, implements and monitors an individual care plan and comprehensive services’ package for our members. Our goal is to improve the health status, functioning and quality of life for SWH members in their preferred place of residence.
Requirements - Massachusetts Registered Nurse License; strong clinical and assessment skills; outstanding communication skills; self-motivation, organization and flexibility; commitment to improve care in underserved populations; collaborative work style; relationship building; entails meeting directly with members, their families and providers in home and office settings; high level of accountability; reliable transportation; computer skills. Home care, long term care, care management experience a plus.
Also seeking a Nurse Care Manager, SNF for the Southern Region, based out of Raynham.
Manager, Credentialing
The Manager, Credentialing is responsible for managing the credentialing team and the provider credentialing at SWH. The Candidate will act as a liaison between SWH and its delegated relationships regarding provider credentialing activity and ensures all accreditation and state and federal regulations are strictly adhered to.
Responsibilities include, but are not limited to:
- Manage the day-to-day operations of the credentialing staff.
- Develop and implement departmental policies and procedures for credentialing activities that meet accreditation, state and federal credentialing standards and regulations
- Monitor and maintain timeliness of all credentialing activity and reporting consistent with regulatory and policy requirements
- Maintain current credentialing and contracting information in the provider database
- Manage the implementation, distribution, and execution of provider/vendor contracts
- Troubleshoot all credentialing and database issues
- Perform credentialing audits as needed
Qualifications:
- Bachelor degree desired, High School Diploma or equivalent required
- 3-5 years experience working in provider credentialing with knowledge of NCQA requirements
- Previous supervisory experience preferred
- Proficiency in using Microsoft Office Products
Community Resource Coordinator
The Community Resource Coordinator (CRC) will work directly with members, Case Managers, providers and community service organizations to ensure that members have access to the range of supportive services needed to promote optimal functioning and quality of life. The CRC will educate the member regarding plan benefits, identify and arrange needed social and health support services and follow up with the member on an ongoing basis.
Responsibilities include, but are not limited to:
Qualifications:
- Extensive knowledge and experience with community organizations, social services and public resources
- Outstanding communication skills
- Willingness to meet directly with members, their families and providers in office or home settings
- Flexibility
- Self starter with high level of accountability and responsibility for outcome of care
- Highly organized and able to manage multiple priorities appropriately
- Able to work collaboratively and build enduring relationships with providers, community and social service organizations, members and the multidisciplinary team
- Bi–lingual Spanish/English required for positions in our Cambridge Office
- Bi-lingual Haitian Creole/English required for positions in our Raynham Office
Quality Specialist, Accreditation
The candidate will work closely with the Director of Quality and other SWH departments to prepare the NCQA (National Committee for Quality Assurance) Accreditation survey.
Responsibilities include, but are not limited to:
- Assist in developing support documentation for NCQA Accreditation survey
- Develop, review and revise health plan policies and procedures across multiple Medical Affairs functions
- Establish working relationships with key individuals in the areas of utilization management, care management and client services to help identify and record key activities crucial to supporting the NCQA Accreditation Standards
- Help identify gaps in NCQA compliance across diverse functions in the organization and work collaboratively with leaders to fill those gaps
- Assist in monitoring initiatives to support improvement of HEDIS and Star Ratings
Candidate will have a Bachelors Degree and a clinical/healthcare background. Masters or RN preferred. Minimum 5 to 10 years of quality assurance/management experience in a managed care setting. Experience with State and Federal (CMS) healthcare regulations and NCQA.
Actuary
The Actuary supports the development of the annual Medicare bid, in cooperation with our actuarial consultants, to ensure adequate Medicare revenue in the upcoming year. The candidate advises the organization of changes in reimbursement and their effect on the business (i.e. cost trends), develops the claims forecast for the annual budgeting cycle and monitors variance throughout the year. The candidate will model out potential arrangements, offer expertise on how the changing arrangements affect behavior, and calculate any year-end reconciliations resulting from provider risk-sharing arrangements.
Responsibilities include, but are not limited to:
- Provide analyses to support provider negotiations and alternative payment models
- Support the CMS bidding process through coordination with external consultants and internal stakeholders
- Develop claims forecasts as part of the annual budget cycle
- Manage a staff of analysts to complete the items above as well as monthly reporting and ad hoc analyses
- Lend subject matter expertise in areas such as statistics, credibility and healthcare data reporting standards
Fellowship in the Society of Actuaries (or near FSA) required and 4-6 years in a managed care payer environment. Familiarity with Medicare Advantage bidding and reporting necessary. Experience with development of provider reimbursement models and subsequent negotiation essential. Claims forecasting experience preferred. Strong problem solving skills – ability to tackle new problems with minimal guidance.
Extremely advanced Excel skills and strong Access and SQL skills. Very good communication of technical ideas to a non-technical audience.
Last modified: 02/02/2012