Comm Health Plan of WA - Manager of Enrollment

http://chpw.org/about-us/careers

 

POSITION PURPOSE:

Responsible for assisting the Manager of Enrollment with the implementation quality of Enrollment Operations deliverables and effectively supervising the Enrollment team and day–to–day activities to ensure exceptional performance. 

 

PRINCIPLE DUTIES:

 

·       Provides technical expertise in composing grievance resolution letters to ensure regulatory and contractual compliance.

·       Provides compliance with CMS and State regulations as they relate to Eligibility processes and appeals and grievance issues.  Must have detailed understanding of the regulatory issues relating to appeals and grievances and how they interact with the work of other departments.

·        Responsible for performing Model Audit Rule (MAR) internal control activities in accordance with Internal Audit standards.  Coordinate with internal and external department personnel in order to ensure that internal controls are operating effectively and that MAR process documentation reflects current work practices.  This position will also include responding fully and openly to inquiries made by CHPW and external representatives. 

 

·       Participates in and oversees the work involved in audits as needed

·       Directs and monitors work assignments, delegation of projects and timekeeping records for direct reports.

·       Develops and implements a monitoring program for activities related to Eligibility including member applications, TRR and LIS submissions.

·       Establishes policies and procedures for the eligibility processes, desk procedures and policy changes.

·       Responsible for all aspects of supervision including hiring, performance management, training, and building a cohesive and supportive work environment. 

·       Coordinates premium reconciliation activities with the Finance Department on a monthly basis.

·       Meets all standards for turnaround and quality as mandated by CMS for Eligibility.

·       Assists with development and disseminates regular reports on department activities to interested parties, integrating suggestions and recommendations.

·       Responsible for improving production processes on a continuous basis, as well as for training all staff on changes and updates.

·       Fosters strong professional working relationships with others in the company and external agencies to assist in the implementation and improvement of interdepartmental processes and/or to meet contractual compliance.

·       Actively supports and participates in company quality initiatives.

·       Other duties as assigned.

QUALIFICATIONS:

 

Education

Required:

Bachelor degree in related field and/or 5-7 years equivalent work experience required.

 

Prior Related Experience

Required:

• Minimum 3+ years of managed health care (or health insurance) experience particularly in the areas of operations and eligibility, project management, process improvement, and employee supervision.
• 2+ years working in a Health Plan required with emphasis on Eligibility requirements and understanding of CMS and State policies.

 

 

Preferred:

• Experience with State programs such as Medicaid and Medicare.  

 

 

Employment Eligibility:

·       Candidate has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.

 

Knowledge, Skills and Abilities:

·       Skilled in all aspects of employee supervision, including hiring, performance management and coaching.

·       Excellent communication skills, both verbal and written.

·       Ability to maintain a professional demeanor and confidentiality.

·       Demonstrated project management skills including the ability to implement new programs and products.

·       Process improvement and management skills and knowledge.

·       Strong analytical and problem solving skills.

·       Ability to work effectively with and support various levels of management.

·       Sensitivity to the needs of every individual to be treated with respect and fairness.

·       Must be able to work with a variety of people and circumstances.

 

SENSORY/PHYSICAL/MENTAL REQUIREMENTS

 

Sensory*:

·       Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

 

Physical*:

·       Extended periods of sitting, computer use, talking and possibly standing.

·       Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion.

·       Frequent torso/back static position; occasional stooping, bending and twisting. 

·       Some kneeling, pushing, pulling, lifting and carrying (not over 25 pounds), twisting and reaching.

 

Mental:

·       Frequent decision-making. Ability to gather and assess data, determine appropriate actions, apply protocols and knowledge to unique situations, problem-solve and provide consultation.

 

* Candidates whose disabilities make them unable to meet these requirements will still be considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.

 

 

WORK  ENVIRONMENT

Office environment with frequent environmental exposure to low-grade radiation from computer monitors; fast paced with frequent interruptions.

 

 

PROTECTED HEALTH INFORMATION (PHI) ACCESS

Community Health Plan employees will encounter protected health information in the regular course of their work at and for Community Health Plan. Community Health Plan is a Covered Entity engaging in Health Care Service Contractor treatment, payment and operations. The following scale intends to provide some indication of how often the employee may encounter or work with PHI in this particular role.  All PHI shall be used and disclosed on a Need To Know Basis and according to HIPAA Privacy Rules Part 164.  In addition, every employee shall sign a confidentiality agreement as a condition of employment and violation of that agreement and/or Community  Health Plan policies can be cause for termination. 

 

PHI is defined at 164.103 as:

"Protected health information means the individually identifiable health information that is (i) Transmitted by electronic media; (ii) Maintained in electronic media; (iii) Transmitted or maintained in any other form or medium.

Individual means the person who is the subject of protected health information.

Individually identifiable health information is information that is a subset of health information, including demographic information collected from an individual, and:
(1) Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and
(2) Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and
(i) That identifies the individual; or
(ii) With respect to which there is a reasonable basis to believe the information can be used to identify the individual.

This position as described will use, encounter, read, create, disclose and or work with in general, PHI that is created by or received by Community Health Plan:

 

• Frequent - The position has frequent and/or daily access and responsibility for PHI.  Need to know.

In all cases, PHI use and disclosure is limited to the minimum necessary amount of PHI needed to complete the treatment, payment or operations.

 

The above is intended to describe the general content of and the requirements for satisfactory performance in this position. It is not to be construed as an exhaustive statement of the duties, responsibilities or requirements of this position.