POSITION: Credentialing Specialist

REPORTS TO: Director, Credentialing Department

SCOPE OF POSITION:

Maintain an efficient provider credentials system by ensuring completed credentials CAQH profiles and/or applications are received and processed, correct data entry, and updated regulatory and credentialing documents are entered and/or scanned into the Doctors HealthCare Plans, Inc, (“DHCP”) credentialing CACTUS database, provide data entry and clerical support to the Credentialing Department.  This position will assist the Credentialing Department in the timely processing of Initial Credentialing / Recredentialing of application, processing incoming and outgoing documents, and requesting required credentials documents.

ESSENTIAL JOB FUNCTIONS:

• Processing practitioner credentialing and recredentialing application packets which includes:
• Reviewing each credentials application packet for completeness and requesting missing data from the practitioner offices and/or Contracting Department staff;
• Creating a new electronic record in the credentialing database and perform data entry of all Initial (new) and Reappointment (recredential) Practitioners (MD, DO, DPM, OD, CH, PA, NP, MW, MSW, CSW, LCSW, MFT, RD, LN, and Ancillaries) credentials applications;
• Requesting by telephone, electronically, fax or mailings State licenses, Drug Enforcement Agency (DEA) certificates, Liability insurance, National Practitioner Database (NPDB) Report, Office of Inspector General (OIG) reports, Board certification, School/Residency/Fellowship  completion, Hospital privileges verification, System Award Management (SAM), Claims history, Accreditation (ancillary facilities), Site Visits and obtaining additional information or clarification from practitioner offices as needed;
• Creating file folders for each new practitioner (e.g. Physician, Ancillary, and or Allied Health Practitioners). 
• Processing practitioner recredentialing application within 3 years of initial credentialing date.
• Processing and maintaining delegated entities’ files, submitted documents and perform data changes which includes:
• State licenses, DEA certificates, Liability insurance, NPDB report, OIG reports, SAM report, Board certification, Hospital privileges verification, claims history, Accreditation (ancillary facilities), and obtaining additional information or clarification from practitioner offices as needed;
• Creating and/or updating electronic records in the credentialing database by entering data, faxing, and/or scanning;
• Filing or scanning documents received.
• Assisting Credentialing Director or designee with various tasks, as needed.
• Receiving, sorting, and distributing incoming mail and faxes as needed.
• Maintaining thorough operational knowledge of the DHCP Credentialing CACTUS Database.
• Maintaining thorough operational knowledge of the appropriate Credentialing Policies & Procedures.
• Annually providing input into updating Credentialing Procedures.
• Performing other related duties as required.

QUALIFICATIONS:

• High school diploma or equivalent; Associate degree is preferred.
• Minimum of two (2) years previous experience in a managed care organization’s Credentialing department.
• Knowledge of basic medical terminology.
• Ability to analyze data and make appropriate decisions.
• Ability to work as a team under stressful conditions.
• Good verbal communication skills (Fluent in Spanish – preferred but not required)
• Excellent organizational skills.
• Extremely detail-oriented.
• Ability to maintain confidentiality.
• Minimum typing skills of 45 WPM.
• PC proficiency and Windows®-based software knowledge (Microsoft Word, Excel, Outlook) required.
• Telephone and customer service skills.
• Scan, Fax, Copy machine.

CERTIFICATE/LICENSE: 

NAMSS CPCS certification is preferred, or a commitment to pursue certification within two years.

Note:  This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s).  Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.   

Apply for this position now by completing the following form:

DEPARTMENT: Enrollment Department

POSITION TITLE: Enrollment Coordinator                            

REPORTS TO: Director of Enrollment

POSITION PURPOSE:  The Enrollment Specialist is responsible for performing duties related to enrollment of Medicare beneficiaries (in the Medicare Advantage Health Plans) and Medicaid beneficiaries. Knowledge of Medicare Advantage Guidelines per CMS Chapter 2, and knowledge of transactions between CMS and health plans. Excellent oral and written communication skills including good grammar, voice and diction. Able to read and interpret documents. Proficient in MS Office with basic computer and keyboarding skills.  Detail oriented and highly organized. Excellent customer service skills (friendly, courteous and helpful).

KEY RESPONSIBILITES:

• Adheres to Processing guidelines to meet Enrollment timeliness requirements as defined by CMS and other regulatory agencies;
• Analyze the member application and accompanying documents, ensuring applicant eligibility and match to CMS’s records;
• Accomplishes daily enrollment, plan changes and disenrollment operations, including application review, entering applications into system and submissions to CMS;
• Conduct calls to beneficiaries, to request additional information to be able to process application requests, plan changes, coordination of benefits;
• Monitors and works closely with providers to obtain confirmation of condition for members enrolled in SNP plans or with SSBCI benefits;
• Identify members
• Be able to reconcile and analyze each section of Daily TRR report, including enrollments and disenrollment’s, Multiple Transactions, Special Status Codes, such as ESRD, and State and County Code (SCC), Analyze and update member records. Contact members via telephone and letter to obtain information necessary to resolve discrepancies. Generate and process appropriate letters;
• Researches eligibility discrepancies and compiles and submits necessary supporting documentation to RPC for correction to CMS.
• Be able to process and maintain the Late Enrollment Process, OOA, CSNP and DSNP process.
• Review and update PCP reports, error reporting, daily processing files from CMS and other processing related tasks
• Responsible for processing of returned mail to ensure integrity of member records. Interface with departments to fulfill company and members requests and resolve member issues.
• Responsible for informing the Medicare Enrollment Manager of all unresolved issues or questions and act as facilitator to resolve them.
• Assist department with all functions on an as needed basis in regards to enrollments, disenrollment’s, LEP, OOA, Enrollment and Disenrollment Monthly Matrix, CTM and RPC.
• Coordinates with Sales & Marketing department on initial application process.
• Performs other duties as assigned.
• Ensure proactive customer service techniques with the highest degree of courtesy and telephone etiquette.
• Comply with all applicable Policies and Procedures.
• May be asked to lift boxes, up to 5 pounds.
• Must be able to work overtime, weekends as business necessary.
• Review and mail all letters to members in accordance with regulatory guidelines.
• Excellent communication skills, verbal and written
• Able to identify priorities, plan work schedule, meet deadlines, able to manage multiple tasks and frequent interruptions
• Reviews monthly CMS reports including: LISHIS, LIS, special TRR, Plan Payment Report, and Demographic Report. Compares reports to eligibility file and resolves any discrepancies
• Work in fulfillment center printing letters, ID Cards, and general mail processing. 

Individual Responsibilities:

• Must be able to prioritize work with administrative deadlines.
• Show initiative in problem solving and be open to new ideas
• Able to work independently and in teams with close attention to detail
• Communicate directly and avoid gossip
• Arrive on time for work or contact manager when delayed
• Be reliable in attendance and give ample notice for absences
• Come to work with a positive attitude

 QUALIFICATIONS:

• High school diploma or general education degree (GED) required.
• Bilingual (English/Spanish).
• A minimum one-year related healthcare industry including Medicare Advantage and Part D experience and patient/beneficiary services.
• Understanding of healthcare terminology and definitions.
• Strong Verbal/Written communication skills

Note:  This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s).  Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.   

Apply for this position now by completing the following form:

POSITION TITLE:      Manager – Fraud, Waste & Abuse

REPORTS TO:           Sr. Director – Operations

POSITION PURPOSE: 

The Manager – Fraud, Waste & Abuse (FWA) is responsible for day-to-day activities of the FWA Program while meeting operational and service requirements in compliance with CMS, AHCA and other regulatory state and federal guidelines.

KEY RESPONSIBILITES:    

• Responsible for administering the FWA Program, FWA WorkPlan, and related activities
• Detect, investigate and report fraud, waste and abuse cases
• Lead special investigations, maintain FWA records, submit to I-MEDIC
• Partner with the Internal Audit/Recoveries Unit and other area to help mitigate FWA
• Develop and implement corrective action plans; track accomplishment of corrective action plan and area statistics
• Educate providers, vendors and members on how to identify and report FWA cases
• Ensure compliance with state and federal regulators
• Prepare the FWA Quarterly Report for the Compliance Committee

The above statement reflects the general duties considered necessary to describe the principal functions of the job identified and shall not be considered as a detailed description of all work requirement inherent to the position.

QUALIFICATIONS:   

• Bachelor’s degree desired
• Five years of experience in Medicare Advantage Plans or healthcare industry at large

• Proven track record in FWA, special investigations and risk assessment

• Knowledge of claims, benefits and provider contracts
• Capable of researching complex issues and applying critical thinking

Note:  This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s).  Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.   

Apply for this position now by completing the following form:

Job Title: Medical Management Coordinator RN

Department: Medical Management

Reports to: Director, Medical Management

FLSA Status: Exempt 

Location: Miami-Dade County

POSITION PURPOSE:  Evaluates and approves requested services using organizational policies or MCG® screening criteria.

KEY RESPONSIBILITIES:

• Manages appropriate cases that require medical necessity review such as home care, elective inpatient and outpatient service requests.
• Reviews cases referred by the prior-authorization non-clinical medical management coordinator and pre-certification technician staff according to member benefits, provider availability, and pre-determined medical necessity criteria.
• Clearly and succinctly presents cases to ensure quality care while advocating for appropriate utilization of health system resources consistent with health plan’s policy, criteria guidelines, and goals.
• Clearly and succinctly documents necessary and/or required information in Utilization Management system.
• Monitors and complies with all state, federal and regulatory requirements relative to accuracy and turnaround times.
• Uses clinical subject matter expertise, as well as knowledge of the interconnection between Utilization Management, claims, and regulatory requirements to respond to complex and/or escalated inquiries.
• Identifies members who could benefit from care management and refers to the appropriate care manager.
• Utilizes critical thinking skills to identify process issues and problems, and recommend and/or implement solutions.
• May identify workflow and systems improvements to enhance Utilization Management’s ability to monitor, document and improve key department performance indicators.
• Uses clinical expertise and analytical ability to identify opportunities for new approaches to better address the needs of targeted members, improve outcomes, stakeholder satisfaction, or department effectiveness.
• Maintains caseload volume, complies with contractual requirements regarding turnaround times, and meets department productivity standards.
• Works collaboratively with internal constituents to understand and successfully meet the goals of the department and organization.
• Builds effective external relationships with business partners such as providers, facilities, and vendors to support program effectiveness.
• Uses Utilization Management system platform with proficiency.

The above statement reflects the general duties considered necessary to describe the principal functions of the job identified and shall not be considered as a detailed description of all work requirement inherent to the position.

QUALIFICATIONS:

• Bachelor’s Degree in Nursing or Nursing School Degree with equivalent relevant work experience.
• At least 3 years of related experience in an acute care or health insurance environment.
• At least 2 years of experience with pre-authorization, utilization review/management, case management, care coordination, and/or discharge planning.

KNOWLEDGE / SKILLS / ABILITIES:

• Bi-lingual preferred.
• Ability to create positive work environment and dynamic with individuals and groups.
• Ability to take action in solving problems exhibiting sound judgement.
• Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts.
• Demonstrates strong organization and time management skills.
• Able to work in a fast-paced environment; ability to multi-task.
• Experience with standard Microsoft Office applications, particularly MS Outlook, Word, Excel and other data entry processing applications.
• Strong analytical and clinical problem-solving skills.
• Ability to work OT during peak periods.

Apply for this position now by completing the following form:

Job Title: Medical Management Coordinator
Department: Medical Management
Reports to: Medical Management Director
Location: Miami-Dade        

 KEY RESPONSIBILITES: 

• Point of contact for providers regarding medical/behavioral/clinical services or benefits.Including (e-g notification, authorization).
• Extract and review fax requests for medical or clinical services requests.
• Receive calls requesting medical/clinical services or benefits information, respond to and transfer calls to appropriate individuals, warm transfer if applicable.
• Gather informationto understand requests based on urgency. 
• Follow protocols to task requests appropriatelyby checking procedure codes against notification requirements and benefit coverage to determine next steps. 
• Take calls and questions from providers regarding case statusand provide/explain authorization information to providers. 
• Determine whether authorizations are required for requested medical services.
• Reference tools to research relevant rules, regulations or procedures.
• Enter requests to relevant system as needed. 

QUALIFICATIONS: 

• Bilingual: English/Spanish preferred
• 2 years + experience preferred
• Proficient with computers
• Excellent organizational skills

Note:  This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s).  Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.   

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Job Title: Licensed Sales Agent (Miami-Dade & Broward)

Department: Sales and Marketing Department

Reports to: Ariel Rodriguez

Location: Miami-Dade

POSITION PURPOSE:

The Licensed Sales Agents sells MAPD products in a field setting.

KEY RESPONSIBILITES:

• Makes sales presentations to potential qualified Medicare participants at their homes, doctors’ offices, etc., using approved governmental guidelines
• Initiates sales opportunities with seniors–individually or in groups–to sell individual health plan policies
• Makes on-site presentations to prospective seniors or senior groups to increase enrollment
• Qualifies prospects on site and closes sale when possible
• Makes decisions on moderately complex to complex issues regarding technical approach for project components
• Exercises considerable latitude in determining objectives and approaches to assignments

 Competencies:     

• High School Diploma & 2+ years’ experience in a managed health care setting
• Active Florida Health & Life Insurance Licenses
• Bilingual (English/Spanish) preferred
• Ability to establish relationships with community partners
• Strong organizational, interpersonal, communication and presentation skills
• Comprehensive knowledge of Microsoft Office.
• Ability to successfully navigate mobile applications
• High level of self-motivation; ability to accomplish goals independently
• This role requires an individual to have a valid state driver’s license and proof of personal vehicle liability insurance with at least 100/300/100 limits
• Additional Information – Upon offer acceptance you must be able to complete and pass the AHIP certification and DHCP annual training and testing

Note:  This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s).  Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.   

Apply for this position now by completing the following form:

Job Description: MRA Analyst
Position available in Miami-Dade
Employment Status: Full-time/Salaried/Exempt 

This is a hybrid position. In most cases the employee will work from home, but may occasionally be required to visit their assigned PCP’s to review paper charts and/or distribute reports.

Responsibilities:           

• Reviews medical records to verify appropriateness of medical record diagnosis, supporting documentation and coding for services rendered to members.
• Identifies, analyzes and addresses documentation and/or coding discrepancies within the medical record / progress note and the submitted encounter / claim.
• Actively problem-solve with utilization or effective communication skills and distribution of corporate approved MRA education materials.
• Analyzes corporate originated MRA reports to identify and confirm unreported and/or unresolved medical conditions of members based on supportive medical documentation.
• Tracks and reviews high volumes of encounters/claims data based on completed MRA reports to evaluate the accuracy of provider submitted diagnosis codes
• Assesses, communicates, and evaluates the provider networks’ process which ensures accuracy and quality of documentation and coding practices.
• Obtains and analyzes information for projects as required by internal business partners and data validation for external regulatory and accreditation bodies.
• Works collaboratively to provide support and resources to internal and external partners Directs applicable questions and/or concerns to the appropriate level/area within the MRA Department/Medical Economic Department
• Maintains confidentiality and compliance with HIPAA regulations at all times.
• Arrives at the review site as early as the office allows them and is required to work a full day, leaving early when a review is not complete is unacceptable. If there is a need to leave earlier, immediate supervisor must be notified.
• Reviews the entire medical record (100%) and not only the date of service for the current MRA year.
• If a documentation pattern is identified with a provider, supplemental documentation must be reviewed and copy/scan as needed. Supplemental documentation includes, but is not limited to: labs, x-rays, consults, or any other type of notes or exams.
• Is required to sit with provider to discuss findings any time before completing on site review. If provider is unavailable, a follow up appointment should be made. Immediate supervisor must be notified.

Requirements/Qualifications:

• CPC, CPC-H, CPMA, CCS, CCS-P or CRC certification
• Preferred: RN, LPN, or foreign physician.
• Proficient in Excel, Word and Power Point
• Bilingual: English/Spanish preferred

Note:  This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s).  Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.   

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Job Title: Provider Relations Representative

Department: Provider Relations

Reports to: VP of Provider Relations

FLSA Status: Exempt

Location:Broward, Tampa Bay, Greater Orlando

POSITION PURPOSE:

Exercise the duties and responsibilities delegated to the Provider Relations Representative with the outmost professionalism and dedication.

KEY RESPONSIBILITIES:

• Responsible for conducting provider orientations of newly contracted providers within the specified time frames as indicated in Policy & Procedure PR – 01.
• Responsible for securing a signed Notice of Educational In – Service Acknowledgement Form upon completion of each and every provider orientation session conducted.
• Responsible for maintaining original completed copies of the Notice of Educational In – Service Acknowledgement Forms in the form and format adopted from time to time by the VP of Provider Relations.
• Responsible for the dissemination of the Provider Handbook / Manual, Provider Bulletins, and applicable Policies and Procedures affecting the Health Plan’s Participating Network of Providers on a “as needed” basis.
• Responsible for conducting the Annual Site Visit for PCPs and High-Volume Specialists within the established time frames as indicated on Policy & Procedure PR – 02.
• Oversight of the participating provider accounts assigned to him/her by the VP of Provider Relations or her assigned designee
• Adhere to the delineated Periodic Site Frequency Parameters as may be applicable to established PCPs and High-Volume Specialists
• Complete the PCP Provider Site Visit Tool to the extent required for each and every Annual and Periodic PCP site visit conducted within their assigned service area
• Complete the Specialty Provider Site Visit Tool to the extent required for each and every Annual and Periodic Specialty site visit conducted within their assigned service area
• Conduct Provider After Hours surveys and periodically monitor the accessibility to access to care to ensure that it meets or exceeds such standards as may be established by CMS.
• Responsible for all communication and training materials distributed to participating providers is up to date.
• Provide assistance in coordinating the Annual Medicare Advantage Health Plan Benefit presentation dinner meetings to Primary Care Physicians and others as needed.
• Active participate in Quality Management Program initiatives and QI special projects as may apply
• Actively participate in the implementation of special projects logistics reporting pertinent to Provider Corrective Action Plans, Provider Surveys, Provider claim dispute settlements, etc.
• Effectively address all matters of Provider complaints and disputes as may be presented for resolution to the VP of Provider Relations
• Maintain accepted and expected level of proficiency in Federal and State regulatory subject matters as mandated through CMS, AHCA and other applicable agencies governing the operations of Medicare Advantage Plans.

Competencies:

• Commitment to the Health Plan’s vision and mission
• Excellent communication skills, both in oral and tabular form
• Fully Bilingual English / Spanish preferred
• BS / BA Degree and/or a minimum of 3 – 5 years’ experience with a Medicare Advantage Health Plan
• Demonstrable knowledge of provider reimbursement methodologies applicable to Medicare Advantage Health Plans and other federal health insurance programs
• Knowledge of CMS, AHCA and other federal and state current regulatory governing guidelines applicable to HMOs
• Excellent organizational skills
• Flexible Disposition to enable management of special projects
• Excellent Customer Service Skills to enable resolution of complex and varied situations involving multiple internal and external stake holders
• Ability to drive key organizational / operational initiatives

Note:  This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s).  Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.   

Apply for this position now by completing the following form: