USHS | U.S. Health Systems

SUMMARY:
The Associate Medical Director of Provider Education is a medically trained individual with extensive knowledge of the CMS HCC-Risk Adjustment Model. This physician must be able to build and maintain strong working relationships with CLIENT providers in an attempt to ensure engagement and cooperation with HCC/STAR initiatives. This individual must work to achieve the goals of the Provider Education team while maintaining a professional, positive and caring attitude at all times.

POSITION DUTIES & RESPONSIBILITES

Educates network providers about quality documentation, coding and billing in regards to CMS HCC Risk Adjustment Model and Quality STAR measures.
Utilizes chart reviews in order to enhance provider knowledge and compliance
Utilizes reports provided to enhance educational opportunities’ and track provider progress
Serves as expert consultant and resource to CLIENT staff and providers in the network
Participates in creating and updating educational tools to be distributed to the network
Collaborates and supports members of multiple departments to enhance success
Demonstrates an in-depth knowledge of the provider network
Demonstrates ability to build strong, positive relationships with providers and office staff
Prioritizes duties to maximize efficiency and quality of work
Manages and promotes provider satisfaction through ensuring proactive service, support and education
Travels to off-site meetings
Actively identifies opportunities for process improvement and communicates best practices to improve overall efficiency.
Assists in the identification and development of standard department procedures
Participates in special projects and other duties as assigned

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.

PHYSICAL DEMANDS
Work Position:

Sitting –70% or more
Standing -less than 25%
Walking -less than 25%

Body Movements:

Lifting 0-25-pounds; books, supplies, files, etc. -Approximately 30%
Bending, stooping and squatting -Approximately 5%
Reaching above head to 75 degrees -Approximately 5%
Grip/hand dexterity; writing –Approximately 60%
Climbing stairs, one flight –approximately 5%

EDUCATION, TRAINING AND EXPERIENCE

Must have graduated from medical school
Prior Experience with education and CMS HCC Risk Adjust Model preferred
Exceptional attention to detail and organizational skills required
Proficient in office equipment (computers, printers, etc.) and MS Office programs
Ability to maintain confidentiality; and ability to multi-task in a high stress environment
Excellent written and verbal communication skills
Must be able to interact with providers in a professional manner with a strong commitment to positively representing the company

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Care Coordination Manager is a non-clinical position responsible for the supervision of the Care Coordinators. Through daily management of Care Coordination staff and participation in day to day activities, ensures all staff delivers outstanding customer service and have the most current knowledge and ability to coordinate services that meet or exceed the organization’s expectations. The Care Coordination Manager works closely with the Director of Care Management, the Director of Clinical Services Operations, the VP of Clinical Services, Medical Directors, and other Internal Departments to maintain regulated timeframe requirements of the contracted Health Plan(s), and maintain exceptional customer service outcomes and positive relationships with internal and external partners. Routinely interacts with physicians, provider office staff, and members.

SPECIFICS

Provides direct oversight of Care Coordinators within the Care Management Department and ensures Arizona Priority Care organizational and departmental policies, procedures and rules are followed and enforced consistently and fairly by all direct reports.
Mentors staff on customer service standards, job role and responsibilities, electronic systems, department expectations and AZPC policies and procedures, and provides assistance as needed.
Distribution of work: Maintain accountability for what work is distributed and to whom.
Auditing of work: 1) Verify that the process in place for processing urgent requests is followed via weekly/daily audits of the staff’s production. 2) Verify that any new process that is implemented is followed by the Care Management staff via daily/weekly audits of the staff’s production.
Ensures that the Care Management Department responds to urgent requests with priority; ensures timely turnaround time to facilitate compliance with health plan regulatory requirements by performing ongoing concurrent monitoring and oversight of the process.
Interacts professionally and communicates effectively with Health Plans, Facilities, staff members, other departments, management, providers, ormembers, etc., regarding Care Management issues.
Participates in the development of Organizational goals and actively contributes to the achievement of assigned departmental goals.
Understand and promote the principles of Care Management to facilitate the right care at the right time in the right setting.
Ensures timely and accurate processing of all levels of appeals.
Work with Director of Clinical Services Operations to update Standard Operating Procedures and Policies to ensure they are current, accurate, and available to staff.
Ensures maintenance of current and accurate electronic reports, files, and other documents for Care Management Department.
Conducts performance evaluations and formulates disciplinary action plans, as appropriate.
Processes timecards as assigned
Ensures maintenance of monthly on-call schedule, assignment sheets, phone lists, and PTO calendar for all Care Management staff.
Maintain current knowledge of all insurance contracts, including but not limited to HMO, PPO, private, and Medicare.
Other duties as assigned by Directors or VP Clinical Services

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice AZPC’s mission, vision and values.
Follow Employee Handbook guidelines and AZPC policies and procedures.
Promote departmental and organizational goals.
Embody AZPC’s values of Integrity, Quality, and Service, Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with AZPC policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.

PHYSICAL DEMANDS
Work Position:

Sitting - 70% or more writing, typing and answering telephones.
Standing - less than 25%; at copier, filing, etc.
Walking - less than 25%

Body Movements:

Lifting 0-20-pounds; books, reams of paper, files, etc. 25%
Bending, stooping and squatting 25%
Reaching above head to 75 degrees less than 25%
Grip/hand dexterity; writing – over 50%
Climbing stairs 0-10 times per day

EDUCATION, TRAINING AND EXPERIENCE

Previous experience with and current working knowledge of Utilization Management concepts, Concurrent Review processes, and workflow.
Has in-depth knowledge of AZPC Policies and Procedures
Minimum of one year supervisory experience preferred
Excellent communication, attention to detail and problem solving skills.
Knowledge of computer applications, including Word, Excel. EZ-Cap experience, Visio and OneNote skills preferred.
Excellent time management and organizational skills.
Demonstrated excellent customer service and telephone etiquette skills.
Ability to work independently and function well under pressure.
Experience in identifying educational needs of staff and implementing timely training.
Demonstrated ability to work within a team environment and creatively lead staff to achieve organizational goals.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Chief Medical Officer’s (CMO) goal is to create a seamless environment where the clinical aspects of care delivery (i.e. PCPs, Care Center, Specialists) and the traditional “health plan” administrative functions complement each other in a care delivery model that avoids unnecessary hospital admissions and readmissions and promotes safe definitive care in the outpatient setting. This job has two distinct aspects that must be combined to facilitate successful outcomes.

Aspect #1: Clinical Leader CLIENT’s Clinics/Care Centers Time & Effort ~ 70%

Definitive Point of Need Care
(Advanced Urgent Care)
Physician Directed Case Management
(Chronically Ill/Frail Elderly)

Qualities
Strong clinical background (hospitalist)
High Energy
Resourceful
Relentless
Empathetic
Confident
Egoless

Qualifications
Several years of clinical experience, preferably as a hospitalist but definitely caring for chronically ill patients will multiple comorbidities.
Experience in supervising and motivating physicians as well as the ability to influence (read change) physician behavioral to affect successful outcomes in this unique environment.

-Medical Doctorate or Doctor of Osteopathy Degree required with appropriate Board Certifications or qualification and level of expertise typically gained through five years’ experience in clinical practice.
-Must be eligible for or hold a current state license to practice medicine and be eligible for medical staff privileges.

The CMO will be responsible for delivering a safe and effective clinical environment to achieve our goals

Staff
Hospital & Clinic Physicians
Clinic Nurses
Social Workers
Medical Technicians
Patient Administrative Support

Aspect #2: Oversight of Administrative Functions Time & Effort ~ 30%

Utilization Management
Case Management
Quality Improvement
Regulatory Compliance
Credentialing

Qualities
Strong/creative UM experience
Realistic approach to Case Management
Evidenced-based approach to QI
First-hand regulatory knowledge
Able to read and apply payor requirements

Qualifications
Three to five years’ medical administrative experience preferably with emphasis on Medicare Advantage members and Medicare rules and regulations. Experience in developing utilization protocols and supporting and motivating the clerical and nursing staff is important. Confidence in medical decision making and strong peer communication skills are a must.

-Medical Doctorate or Doctor of Osteopathy Degree required with appropriate Board Certifications or qualification and level of expertise typically gained through five years’ experience in clinical practice.
-Must be eligible for or hold a current state license to practice medicine and be eligible for medical staff privileges.

The CMO will have the supervisory and support staff necessary to carry out the administrative functions listed above.

Staff
Medical Director
Director UM, QI, Compliance
Nurse Managers
Field Nurses
Office-Based Nurses
Clerical Support Personnel

We offer a Competitive Salary & Bonus Potential package and a full range of benefits. You will report to the Chief Operating Officer who is responsible for Arizona Operations. You will have an opportunity to be on the cutting edge of health care delivery.

The information below was shared with our PCPs to describe what CLIENT will do in addition to the traditional administrative functions. We include it to give you a better understanding of our organization and concept.

Medical Home

We believe that the Medical Home is, in many settings, an aspirational goal that when achieved it will bring positive change to the delivery system and more importantly, enhance patient outcomes. Client (CLIENT) can add value to your already successful practice by providing the complementary services that create the Medical Home environment without additional cost to the practice.

Physician Directed High Risk Case Management
Point of Need Care
Transitional Care Responsibility
Specialty Consultation Assistance

Physician Directed High Risk Case Management. In general, the current Primary Care Practice model works well for the better than 90-95% of patients. Many have chronic diseases that are relatively stable and occasionally have acute self-limiting illness that needs your attention. It is the 5-10% that have multiple comorbidities some out of control, poor health habits, socio-economic barriers to care that need more time and more care than the routine primary care practice can provide. This is indictment of the primary care practice but rather the complications of the delivery system and compensation models that make extending this level of care virtually impossible.

We want you to feel comfortable referring these more difficult patients to us for a short duration. Our primary care physicians will quickly get up to speed on your most complex patients and work with them on a daily basis if necessary to return them to the best level of health possible given their circumstances and return the patient to your practice for follow-up care. We keep you, the primary care leader, in the loop during the complex care episode through bi-weekly patient conferences with the CLIENT physician. Additionally, our case management staff will schedule appointments, conduct patient education, monitor clinical indicators, optimize prescription drug access and compliance and eliminate barriers to receiving good care. It’s almost like sending your patient to an intensive care management spa to get their health back in balance.

Transitional Care Responsibility. We will take ownership of the patient when you hand them off for hospitalization, SNF or Home Health care. Our hospitalists will provide impatient and SNF care responsibility. Our care management nurses and technicians will assess, educate, and coordinate all transition activities. Most importantly, we will follow-up with each patient to make sure that the care plan is working and adjust the plan to insure optimal success.

Specialty Coordination Assistance. Keeping with the medical home concept, we believe that you, the primary care provider should have a high degree of influence in helping the patient make the right decision. We will select preferred specialists that will give objective opinions on treatment options and refer the patient back to you with information that allows you to help the patient make the best decision.

Comprehensive Health Assessment. We believe that an annual comprehensive health assessment allows the PCP and CLIENT’s extended care team to develop a better plan of care that will result in better outcomes. We have developed a tool that will document the patient’s condition and serve as the basis of the on-going care plan. This care plan will also be the basis for submitting data to CMS for appropriate risk score coding. This will be an important factor in the Provider Incentive Program

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Care Manager is responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation for members including those being cared for in a skilled nursing facility (SNF). The Care Manager will assess and develop a care plan in collaboration with the admitting, attending and consulting physician, the member and other health care practitioners. The goal of the Care Manager is to effectively manage members to assure the appropriate level-of-care is provided, to prevent inpatient and SNF re-admissions and ensure that the members’ medical, environmental and psychosocial needs are met over the continuum of care in the least restrictive environment.

SPECIFICS

Keeps member/family members or other customers informed and requests if necessary, further assistance when needed.
Demonstrates the ability to follow through with requests, sharing of critical information and getting back to individuals in a timely manner.
Performs and documents member assessment and reassessment, member care plans, and other pertinent information including SNF discharge planning; completed in the member’s medical record in accordance with the PIP Charting methodology, nursing standards, and company policies and procedures.
Initiates PRN home visits to assess patient progress.
Identifies planned and unplanned transitions of care from Requests for Services or daily inpatient and SNF census.
Identifies the appropriate members to participate in the interdisciplinary case rounds. Prepares the necessary summary information to present to the team.
Participates in the interdisciplinary team, along with physicians, social worker and other health care practitioners to develop individualized care plan.
Functions as a liaison between administration, members, physicians and other healthcare providers.
Educates the member/caregiver on the transition process and how to reduce unplanned transitions of care.
Manages transition of care at every level ensuring that the Plan of Care moves with the member and updates/modifies the care plan as the member’s health care status changes.
Communicates appropriately and clearly with physicians, in patient care managers and Prior-Authorization nurses
Identifies and addresses psychosocial needs of the members and family and facilitates consultations with Social Worker, as necessary.
Identifies community resources to address needs not covered by the member’s benefit plan, and coordinates member benefits as needed, with the health plan.
Participates in the efficient, effective and responsible use of resources such as supplies and equipment.
Continues to telephonically follow and care manage those complex members who require further post-hospitalization/SNF monitoring post discharge.
Ability to collaborate and communicate with all members of the healthcare team (concurrent review, pre-authorization, PCP/SPC, Social Services) to coordinate the continuum of care of developing plans for management of each case.
Identifies and submits to the Quality Improvement Committee any potential or actual quality issues for their review as well as utilization issues; e.g., over/under utilization, delay of services issues, etc.
Responsible for the identifying members that are appropriate for hospice conversion or Palliative care.
Other duties including on-call duties as assigned.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.

PHYSICAL DEMANDS

Work Position:

Sitting - 70% or more writing, typing and answering telephones.
Standing - less than 25%; at copier, filing, etc.
Walking - less than 25%

Body Movements:

Lifting 0-20-pounds; books, reams of paper, files, etc. 25%
Bending, stooping and squatting 25%
Reaching above head to 75 degrees less than 25%
Grip/hand dexterity; writing – over 50%
Climbing stairs 0-10 times per day

EDUCATION, TRAINING & EXPERIENCE

Graduate from an accredited Registered Nursing Program
Current AZ RN license without restrictions and valid AZ Driver’s license.
3 years acute care or case management experience.
2-3 years of utilization or HMO experience preferred.
Typing 40 words per minutes with accuracy.
Knowledge of computers, faxes, printers and all other office equipment.
Knowledgeable in MS Office Programs (i.e., Word, Excel, Outlook, Access and PowerPoint)

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

The Care Manager RN, will concurrently review all member utilizations for medical appropriateness. Make recommendations for alternative levels of care and identify potential barriers or delays in service. Will understand and support CLIENT’s coordination-focused model.

SPECIFICS

Performs the initial hospital admission review, and collaborates with CLIENT Medical Directors, for medical necessity determination for in-network hospitalized members.
Performs re-reviews on all status changes, collaborates with the Medical Director for appropriate status determination.
Performs re-reviews on all disputed claims and collaborates with the Medical Director for medical necessity determination.
Review all Acute Rehab and Long Term Acute Care requests for appropriate disposition with the Medical Director, and informs the hospital case manager of decision.
Documents relevant changes in EZCAP of member’s condition or status, as they occur.
Reviews the admission history and current care transition process of each admission for gaps in the continuum of care and makes recommendations to ICT on how to reduce readmissions and unplanned transitions of care.
Collaborates timely and effectively with Beech/Adobe on case management and home health referrals.
Facilitates member/family/caregiver education through referrals to Adobe Case Management.
Identifies any psychosocial needs of the member and facilitates referral to social worker and/or behavioral health, as necessary.
Assists the SNF RN as needed to ensure timely and safe discharges.
Responsible for identifying members who are appropriate for palliative care or hospice conversion.
Identifies and submits to the Quality Department any potential quality issues for review as well as utilization issues; e.g., over/under utilization, delay of service issues, etc.
Participates and equally shares in after-hour and week-end coverage for Clinical Services Department.
Strong teamwork philosophy and willingness to accept change proactively.
Other duties as assigned.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service, Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.

PHYSICAL DEMANDS
Work Position:

Sitting - 70% or more writing, typing and answering telephones.
Standing - less than 25%; at copier, filing, etc.
Walking - less than 25%

Body Movements:

Lifting 0-20-pounds; books, reams of paper, files, etc. 25%
Bending, stooping and squatting 25%
Reaching above head to 75 degrees less than 25%
Grip/hand dexterity; writing – over 50%
Climbing stairs 0-10 times per day

EDUCATION, TRAINING & EXPERIENCE

Current unrestricted STATE Nursing license – BSN RN preferred.
Knowledge of Medicare, state, and local managed care regulations, prior experience in Managed Care setting preferred.
5 years acute care or care management experience, prior ER or ICU or other relevant clinical role requiring quick critical thinking experience preferred.
Must have the ability to present clinical information both accurately and confidently.
Able to communicate effectively and in a professional manner with all levels of internal staff and external customers.
Ability to be detail-oriented, able to function under pressure and able to prioritize and re-prioritize tasks as needed.
Ability to work both independently and as part of a team, with minimal supervision.
Excellent customer service and communication skills, both oral and written.
Familiarity with Electronic Health Records systems, including NextGen and/or EzCap.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
Client strives to be the network of choice for health plans and employers and the Director of Provider Relations plays a critical role in ensuring high levels of provider satisfaction and development. This position directs the Provider Relations Manager and Representatives. They lead and manage provider education and communications to ensure CLIENT, health plan, and regulatory requirements are clearly communicated and met. They are instrumental and impactful for ensuring providers are educated and aware of the CLIENT tools available for their use.

ESSENTIAL FUNCTIONS

Strengthens relationships with key providers and group practices.
Lead all aspects of Provider Relations to include provider relations and operations to support provider service, provider education, and product and market expansions.
Leads, develops and trains staff to educate key individuals in Hospitals and Provider groups regarding new approaches, products, reimbursement methodologies, appropriate coding including risk scores, and policy or CLIENT standards changes. Creates efficiencies for offices decreasing the administrative obstacles and develops educational programs for staff & providers.
Ensure an effective and timely provider communication and education function
Ensure contracted provider offices have frequent and regular interactions with the Provider Relations team. Track and report on office visit activity and identify issues requiring follow up. Coordinate timely responses on claims issues in collaboration with the Claims team. Escalate issues to supervisor requiring immediate intervention.
Conduct periodic office surveys on effectiveness of provider communications
Partner with HCC/STARS team to conduct effective practice management programs and educational events.
Maintain the provider web page content to ensure information and resources are available to providers on a timely basis including updated provider directory
Assist Marketing department with provider-specific marketing initiatives
Manage budgeting and forecasting and ensure departmental targets are established and maintained
Develop and implement a community outreach strategy with network providers including a communication plan to keep them informed of current issues. Provides input to provider communication such as letters, presentations, training guides and collateral materials as needed.
Develop strong relationships with outside partners, such as vendors and advisors, as well as internal partners, including department supervisors and co-executives.
Assist Provider Relations team in managing strong working relationships with all providers; this may include visits/dinners with providers as needed.
Develops innovative initiatives to enhance internal efficiency and effectiveness
Formulate training programs; maintain efficient team structure and performance through analytics, processes and tools; maximizing new provider engagement; and working with the leadership team to develop plans to meet future needs.
Manages Provider Relations in conjunction with the Provider Relations Manager and Reps and redirects activities as necessary

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice CLIENT’s mission, vision and values.
Follow Employee Handbook guidelines and CLIENT policies and procedures.
Promote departmental and organizational goals.
Embody CLIENT’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with CLIENT policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.

PHYSICAL DEMANDS

Work Position:

Sitting - 50% or more
Standing - Approximately 25%
Walking - Approximately 25%

Body Movements:

Lifting 0-25-pounds; books, supplies, files, etc. - Approximately 30%
Bending, stooping and squatting - Approximately 5%
Reaching above head to 75 degrees - Approximately 5%
Grip/hand dexterity; writing – Approximately 60%
Climbing stairs, one flight – approximately 5%

EDUCATION, TRAINING & EXPERIENCE

Bachelor’s degree or equivalent experience in Business Administration, Healthcare Administration or related field. MBA/MHA preferred. 5+ years of experience in customer service and provider relations in a health care or managed care environment.
Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
Excellent oral and written communication skills
Strong interpersonal and collaborative skills (experience working in a consensus building and matrix environments a plus).
Demonstrated experience and knowledge of CMS managed care contracting requirements

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Facilities Manager is responsible for performing all facility operational services at each Client (CLIENT) location including maintenance and repair. Duties will entail performing and/or coordinating repair work through contractors to keep these facilities in good condition. Coordinates the mailroom function for all locations and aids in the setup of conference rooms for meetings or the relocation of medical equipment as necessary. Must maintain a professional, positive and caring attitude at all times.

ESSENTIAL FUNCTIONS

Coordinates with appropriate organizations and outside vendors to ensure accurate current information is available and documented as part of the performance of Preventative Maintenance (PM) procedures.
Interfaces with management on additions, deletions of modifications to PM procedures as changes to location configuration dictate.
Monitors and analyzes PM reports, work orders and feedback to optimize effective and efficient PM procedures, planning and scheduling.
Coordinates with Supply Management Coordinator for Min/Max items, procurement issues and shipments in addition to purchased support services.
Organizes and schedules specialized training to enhance the overall ability of the department to perform in a sound technical and professional manner.
Coordinates between facilities acting as the central point of contact for mechanical/electrical PM issues.
Oversees mailroom department and processes.
Maintains office equipment, medical equipment, furniture, etc.
Ensures PM activities are consistently and concisely documented.
Initiates and distributes PM status reports to assist in the prioritization of resources and time.
Coordinates all facility mechanical and electrical preventive maintenance activities.
Maintains all plans, procedures, MOPs, SOPs and all other documentation necessary for safe and proper performance of preventive maintenance activities.
Aids in the setup of meeting rooms or the relocation of medical equipment as necessary.
Handles and prioritizes tasks in order to meet all given deadlines and productivity goals.
Coordinate scheduled shred pick-ups.
Coordinates the scheduling of office moves of equipment such as computers, furniture, etc.
Monitors and schedules incoming work requests for timely scheduling and completion.
Supervises and coordinates housekeeping company.
Schedules security coverage at each CLIENT location and monitor alarm systems.
Supervises all Maintenance/Mailroom personnel.
Communicates with all property managers at CLIENT locations.
Communicates with contractors pertaining to ongoing projects and oversee vendors utilized by CLIENT.
Performs other duties as assigned.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.

PHYSICAL DEMANDS

Work Position:

Sitting – typing, filing, phone work, etc. – 60% or more
Standing - Approximately 15%
Walking - less than 25%

Body Movements:

Lifting 0-40-pounds; books, supplies, files, etc. - Approximately 20%
Bending, stooping and squatting - Approximately 10%
Reaching above head to 75 degrees - Approximately 10%
Grip/hand dexterity; writing – Approximately 55%
Climbing stairs, one flight – approximately 5%

EDUCATION, TRAINING & EXPERIENCE

High school graduate or equivalent; Bachelor degree in Business or related field preferred.
Experience in facilities management preferred.
Proficient in office equipment (computers, printers, etc.) and in MS Office programs (Word, Excel, etc.).
Excellent written and verbal communication skills.
Ability to maintain confidentiality; and ability to multi-task in a high stress environment.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
To Review, Assist, Communicate with the HCC team, Administration and Providers regarding HEDIS/Stars program within the IPA community.

SPECIFICS

Run updated individual physician list of eligible members for any/all HEDIS/5Star measures indicating what individual member needs/requires, ensuring that reports/lists of services needed are forwarded to appropriate PCP’s for action and inclusion in member’s medical record.
Coordinates and oversees process for quality surveys which includes: revising collection tools as appropriate and ensuring deployment of tools. Ensures QI has appropriate reports (timely for finalization of comparison reporting.
Enters clinical data that substantiates compliance in iCode/iStar.
Maintains/creates database including informatics troubleshooting and/or program adjustments with Patient & Provider Services (Customer Service) staff. Liaison with iCode/iStar Administrator as needed/appropriate.
Maintains up-to-date physician P4P profiles and assists with reports/paperwork for P4P payout.
Maintains current knowledge and acts as a resource for NCQA Standards relating to HEDIS.
Supports and maintains an environment which fosters high customer and employee satisfaction and quality service (as evidenced by satisfaction surveys, I monitoring results and/or input/comments by others.
Performs other duties as assigned.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.

PHYSICAL DEMANDS
Some equipment lifting and transport is required.
Work independently and within time constraints.
Extensive travel outside of the office.

Work Position:

Sitting – 60% or more
Standing – 20% or more
Walking – 10% or more
Driving – 10% or more

Body Movements:

Lifting 0-10 pounds; documents, supplies, files – Frequency - approximately 10%
Bending, stooping and squatting – Frequency - approximately 15%
Reaching above head to 75 degrees – Frequency - approximately 15%
Grip/hand dexterity – Frequency - approximately 70% of day
Climbing stairs 0-10 times per day

EDUCATION, TRAINING & EXPERIENCE

High School diploma required. College degree preferred.
Minimum 2 years experience in healthcare or managed care setting with responsibility for systems and/or projects.
Knowledge of iCode/iStar, EZCap & NextGen preferred.
Ability to find, gather and collect information or data
Excellent written and oral communication skills.
Ability to work independently once oriented to routine and process.
Intermediate level proficiency with Microsoft Office applications including Word, Excel, Power Point.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
To develop reports, databases, and processes for the STARS/HCC team and Administration regarding HEDIS/Stars program within the IPA community.

SPECIFICS

Design, create, implement, manage, and modify detailed analysis tools for STARS Department.
Run updated individual physician list of eligible members for any/all STAR measures indicating what individual members require, ensuring that reports/lists of services needed are forwarded to appropriate PCP’s for action and inclusion in member’s medical record.
Reconcile STARS reporting data from multiple sources to maintain updated information and run weekly reports for Client to inform the most current status within a 5 Star scale.
Test and troubleshoots databases and reports to verify the accuracy and maintain the integrity of the data.
Enter clinical data that substantiates compliance in qMetrics and STARS Outreach List (SOL).
Research and coordinate processes to obtain data from Health Net for STARS reporting and planning purposes.
Retrieve data for in-patient members within contracted facilities, manage and coordinate reports to communicate with other departments.
Maintains up-to-date physician P4P profiles and assists with reports/paperwork for P4P payout.
Develop modules for provider education outreaches and other CLIENT departments as required with the focus on implementing interdepartmental analytical solutions for STARS improvements and productivity.
Collaborate with the Medical Records Department to appropriately retrieve medical charts from vendors and providers as needed.
Maintains current knowledge and acts as a resource for NCQA Standards relating to HEDIS.
Supports and maintains an environment which fosters high customer and employee satisfaction and quality service (as evidenced by satisfaction surveys, I monitoring results and/or input/comments by others.
Perform other duties as needed.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.

PHYSICAL DEMANDS
Some equipment lifting and transport is required.
Work independently and within time constraints.
Limited travel outside of the office

Work Position:

Sitting – 80% or more
Standing – 10% or more
Walking – 5% or more
Driving – 5% or more

Body Movements:

Lifting 0-10 pounds; documents, supplies, files – Frequency - approximately 10%
Bending, stooping and squatting – Frequency - approximately 15%
Reaching above head to 75 degrees – Frequency - approximately 15%
Grip/hand dexterity – Frequency - approximately 70% of day
Climbing stairs 0-10 times per day

EDUCATION, TRAINING & EXPERIENCE

2-year college degree required. Bachelor’s Degree in computer science or related field preferred.
Minimum 2 years’ experience in healthcare or managed care setting with responsibility for systems and/or projects.
Knowledge of qMetrics, EZCap & NextGen preferred.
Ability to find, gather and collect and interpret information or data
Excellent written and oral communication skills.
Ability to work independently once oriented to routine and process.
Excellent level proficiency with Microsoft Office applications including Word, Excel, Power Point, Access, SQL.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
To Review, Assist with development and Communication with the STARS team, Administration, Providers and members regarding HEDIS/Stars program within the IPA community.

SPECIFICS

Review updated individual physician lists of eligible members for HEDIS/5Star measures, indicating member requirements.
Coordinate and oversee processes for quality, including: creating and revising STAR tools as appropriate and ensuring timely deployment of tools
Review medical records, track and enter data, which substantiate Medicare compliance and validation for audits, into qMetrics and supplemental databases.
Assist with the development, creation and maintenance of databases, including informatics troubleshooting and/or patient and provider services programs.
Coordinate events and/or programs to improve member education and compliance with STAR measures.
Use excellent customer service skills to contact members by phone and mailings in efforts to educate and assist members with completing HEDIS/STAR measure.
Travel to member homes and other facilities for member interaction and providing medical services to comply with STAR measures, (i.e. Bone Density scans, HbA1c testing, Urine testing, and other services).
Create medical records of medical services provided in NextGen EMR system.
Maintain updated physician P4P profiles and assists with reports/paperwork for P4P payout.
Maintains current knowledge and acts as a resource for NCQA Standards relating to HEDIS.
Maintain current knowledge and compliance with standard patient medical care.
Support and maintain an environment which fosters high customer and employee satisfaction and quality service (as evidenced by satisfaction surveys, I monitoring results and/or input/comments by others.
Performs other duties as assigned.
Collaborate and create initiatives for patients and providers STAR success.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.

PHYSICAL DEMANDS
Some equipment lifting and transport is required.
Work independently and within time constraints.
Extensive travel outside of the office

Work Position:

Sitting – 60% or more
Standing – 10% or more
Walking – 10% or more
Driving – 20% or more

Body Movements:

Lifting 0-10 pounds; documents, supplies, files – Frequency - approximately 10%
Bending, stooping and squatting – Frequency - approximately 15%
Reaching above head to 75 degrees – Frequency - approximately 15%
Grip/hand dexterity – Frequency - approximately 70% of day
Climbing stairs 0-10 times per day

EDUCATION, TRAINING & EXPERIENCE

High School diploma required. College degree preferred.
Arizona Medical Assistant Certification
Minimum 2 years experience in healthcare or managed care setting with responsibility for systems and/or projects
Knowledge of qMetrics/qHealth, EZCap & NextGen preferred
Ability to find, gather and collect information and data
Excellent written and oral communication skills
Ability to work independently once oriented to routine and process.
Intermediate level proficiency with Microsoft Office applications including Word, Excel, Power Point, Access

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Medical Assistant for the Provider Home Program is a highly organized, friendly individual who can efficiently multi-task. This position will work interdependently with the Home Program Provider and the Home Program RN to provide quality health care to the patient. The Medical Assistant will utilize both administrative and clinical skills in the Home Program Position.

ESSENTIAL DUTIES & RESPONSIBILITIES

Follow HIPAA policies and use two patient ID on every patient with telephone encounters.
Accurately schedule Home Visit appointments according to providers schedule, schedule specialist appointments, and transportation for the patients.
Request medical records for patients scheduled for home visit appointments and scanning records into EMR.
Conduct reminder calls 24-48 hours prior to appointments.
Follow through with patient referrals, DME orders and other coordination of care.
Obtain comprehensive patient medical history from ICode, EzCAP, Ascendor, hospital and PCP records requests for last 6 months of labs and procedures.
Chart abstraction by entering the information into the EMR and prepare Home Visit Folder for the Provider in advance according to his/her schedule.
Triage phone calls and address patient requests for information/medication refills and/or forward messages to appropriate staff and document appropriately.
Obtain and schedule authorization for outside referrals, DME or testing as ordered by the provider.
Provide patient education with regards to specialist referrals and prior authorization, medications, management of diseases, home treatments, and special diets.
Complete concise, objective and complete documentation of all patient correspondence, via appointment, telephone etc. and route/task appropriately
Follow HIPAA policy with regard to requesting, handling and sending patient PHI
Perform patient follow up visits either via telephone or home visit depending on needs of the patient
Collaborate with program provider and RN on the coordination of patient care.
Other duties as directed

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.

PHYSICAL DEMANDS/WORK ENVIRONMENT:

Office & Clinic setting; prolonged sitting and standing.
Potential exposure to infectious disease, must use universal precautions.

Body Movements:

Lifting - 0 - 60 pounds or more; maneuvering of patients, heavy equipment &, supplies - Frequency – approximately 20%.
Bending, stooping and squatting - Frequency - approximately 10%.
Reaching, including above the head for supplies - Frequency - approximately 10%.
Pushing/Pulling: Frequency - approximately 20%.
Grip/hand dexterity; writing - Frequency - approximately 40%.
Climbing stairs - 0 - 10 times daily.

EDUCATION, TRAINING & EXPERIENCE

Completion of an accredited MA program and MA Certified (state or national)
Extensive knowledge of Microsoft Office applications (Word, Excel, Outlook, and PowerPoint) is required.
Demonstrated personal initiative, team spirit, and service orientation are vital.
Excellent customer service and communication skills required.
Knowledge of office phone systems is required.
Experience with Electronic Medical Record program, NextGen preferred.
Successful experience working in a medical office environment with challenging clients.
CPR Certification

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Home Wellness Program Coordinator ( HWPC) is an allied health professional who under the direction of the Home Wellness Program Supervisor, Nurse Practitioner performs various clinical and administrative duties that supports the initiatives of AZPC HWP.

ESSENTIAL DUTIES & RESPONSIBILITIES: Administrative

Under the guidance of the Home Wellness Program Supervisor collaborates with HWP team members utilizing both clinical and administrative skills.
Obtains and accurately tracks patient/ provider source list
Conducts telephone calls to patients, providers, and other health care professionals and organizations in support of HWP initiatives
Conducts scheduling of patient visits that are conducted by HWP Medical Providers according to HWP established processes.
Demonstrates clear, concise, effective communication with HWP team members to ensure accurate scheduling procedures to support care outcomes.
Provides high quality customer service to both internal and external customers.
Ensures follow-through on patient/provider communications and monitors workload assignments to ensure deadlines are met
Conducts patient visit reminder calls in advance of scheduled “In Home” appointment
Conducts review of electronic health record and other appropriate data source
(QHMO, EzCAP, Business Solutions) in order to construct patient packet for HWP visit.
Request hospital records for patient hospitalizations if applicable.
Assist with coordination of patient referrals upon request of HWP medical provider staff
Creates patient packets in preparation for HWP medical provider visits.
Copy medical information as requested following proper procedures
Scans/enters incoming medical reports and correspondence and files in patient charts and/ or presents to HWP medical provider for review.
Documents clear, concise communications conducted with patients in appropriate data bank (EHR ,Business Solutions, Scheduling Spreadsheets).
Receive and greet patients and visitors utilizing excellence in customer service skills when answering phone calls, addressing verbal and written requests to promote customer satisfaction/problem resolution.
Participates in ensuring the smooth functioning of HWP operations.
Acts as resource person for regarding HWP policies and procedures.
Functions as “problem solver” within area of responsibility and scope of practice
Under the direction of the HWP Nurse Practitioner Supervisor, functions as a liaison to obtain and provide information on diverse and often complex issues.
Recommends procedural changes to enable and enhance HWP efficiency
Participates in the creation, preparation, and updates of various HWP publications such as brochures, letters to patients/members, departmental orientation manuals and various reports as assigned.
Formats documents and edits for accuracy in grammar and spelling.
Collaborates with HWP Nurse Practitioner Supervisor in establishing work priorities keeping in mind the competing demands of the organization
Demonstrates and adheres to HIPAA policies and procedure that include, yet may not be limited to the following functions:
*Patient telephone encounters utilizing two (2) patient identifiers
*Requesting, transmitting, handling patient Protected Health Information
Obtain and schedule authorization for outside referrals, DME or testing as ordered by the HWP medical provider.
Ensures adequate inventory of both office and clinical supplies, keeping accurate records of orders placed, received in collaboration with facilities/purchasing department

ESSENTIAL DUTIES & RESPONSIBILITIES: Clinical

Conducts telephone communication with patient, contributes to assist HWP medical provider in identification of patient needs based on acuity of patient concern and refers patient concerns to appropriate level of care
NOTE: This does not include telephone triage of patient health concerns
Assists the HWP medical provider in identification of client needs and goals for care
Contributes to assessment of the clients/patients health status by:
Recognizing patient characteristics that may affect health status;
Gathering and recording assessment data such as vital signs
Contributes to assisting the HWP medical provider in identification of client needs and goals for care
Contributes to Identification of resources and assists with coordination of services under the guidance and direction of HWP medical provider
Under the guidance and direction of the HWP medical provider, provides health information. This includes, but is not limited to health promotion, chronic disease management resources and annual preventative screening examinations recommendations.
Under the direction and guidance of HWP medical provider may perform point of care testing and screenings such as hemoglobin A1c, arterial brachial index/ PVD screening, hand-held spirometry.
Performs POCT quality controls as outlined in manufacturer’s recommendations and instructions.
Conducts daily refrigerator/freezer temperature log form/ reports variance to supervisor
Ensures HWP equipment supplies are stocked and readily available for patient care visits.
Adheres to CDC standard principles of infection control, hand hygiene
Adheres to OSHA standard principles involving blood borne pathogens and use of universal precautions
Promotes a safe patient environment. Arizona law mandates that certain professionals report abuse, neglect, or exploitation if they have a basis to believe it has occurred.
Other duties as directed

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.

PHYSICAL DEMANDS/WORK ENVIRONMENT:

Office & Clinic setting; prolonged sitting and standing.
Potential exposure to infectious disease, must use universal precautions.

Body Movements:

Lifting - 0 - 60 pounds or more; maneuvering of patients, heavy equipment &, supplies - Frequency – approximately 20%.
Bending, stooping and squatting - Frequency - approximately 10%.
Reaching, including above the head for supplies - Frequency - approximately 10%.
Pushing/Pulling: Frequency - approximately 20%.
Grip/hand dexterity; writing - Frequency - approximately 40%.
Climbing stairs - 0 - 10 times daily.

EDUCATION, TRAINING & EXPERIENCE

High school diploma or GED equivalent required
Completion of 1-2 years post-secondary education preferred
Completion of an accredited MA program and MA Certified (state or national) preferred
Completion of an accredited phlebotomy training program with certification preferred
Understanding of medical terminology
Extensive knowledge of Microsoft Office applications (Word, Excel, Outlook, and PowerPoint) preferred
Demonstrated personal initiative, team spirit, and service orientation are vital.
Excellent customer service and communication skills required.
Knowledge of office phone systems, required.
Experience with Electronic Medical Records
CPR Certification, required

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Home Wellness Program Licensed Practical Nurse (HWP LPN) is a licensed health professional who under the direction of the Home Wellness Program Supervisor, Nurse Practitioner, performs clinical and administrative duties that support the initiatives of the CLIENT HWP.

ESSENTIAL DUTIES & RESPONSIBILITIES: Administrative

Engage in practical nursing only under a licensed physician, nurse practitioner or the supervision of a registered nurse
Accept responsibility for individual nursing actions, decisions, and behavior in the course of practical nursing practice within scope of practice
Follows physician, nurse practitioner orders and seeks clarification of orders when needed
The LPN shall provide input and contribute to the assessment of the clients/patients health status by:
Recognizing patient characteristics that may affect health status;
Gathering and recording assessment data;
Demonstrating attentiveness by observing, monitoring, and reporting signs, symptoms, and changes in client condition in an ongoing manner to the physician, nurse practitioner and supervising registered nurse
Contributes to assisting the physician, nurse practitioner, and supervising registered nurse in identification of client needs and goals for care
Refers patient concerns to appropriate level of care as identified based on clinical nursing decisions within scope of LPN practice
Conducts telephone communication with patient, contributes to assist physician, nurse practitioner and supervising registered nurse in identification of patient needs based on acuity of patient concern
Contributes to Identification of resources and assists physician, nurse practitioner and supervising registered nurse with coordination of services in response to patient healthcare needs
Under the guidance of the Home Wellness Program Supervisor collaborates with HWP team members utilizing both clinical and administrative skills
Provides health information to patients as directed by physician, nurse practitioner and supervising registered nurse or according to an established educational plan regarding health promotion, chronic disease management, and annual screening examinations.
Administers treatments, medications and procedures as directed by physician, nurse practitioner and supervising registered nurse
Performs point of care testing and screening tests as directed by physician, nurse practitioner, and supervising registered nurse to promote outcome measures.
Promotes a safe patient environment
Functions as internal resource for clinical and non-clinical team members to promote positive patient/ customer outcomes
Obtains and accurately tracks patient/ provider source list to promote coordination of visit schedule
Performs scheduling of patient home visits conducted by HWP Medical Providers, licensed and non-licensed clinical staff
Demonstrates clear, concise, effective communication with HWP team members to ensure accurate scheduling procedures to support patient care outcomes.
Conducts telephone calls to patients, providers, and other health care professionals and organizations in support of HWP initiatives
Provides high quality customer service to both internal and external customers.
Conducts review of electronic health record and other appropriate data source to create patient clinical packet for HWP visit.
Assist with coordination of patient referrals upon request of HWP medical provider
Receive and greet patients by answering phone calls, requests and/or forward message to appropriate HWP staff to promote customer satisfaction/problem resolution.
Demonstrates and adheres to HIPAA polies and procedure that include, yet may not be limited to the following functions; (1) patient telephone encounters utilizing two (2) patient identifiers; (2) requesting, transmitting, handling patient Protected Health Information
Participates in the interview and selection process of HWP staff
Participates in the orientation and training of HWP clinical and non-clinical staff
Performs other duties as assigned within licensed practical nurse scope of practice

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:

Office & Clinic setting; prolonged sitting and standing.
Potential exposure to infectious disease, must use universal precautions.

Body Movements:

Lifting - 0 - 60 pounds or more; maneuvering of patients, heavy equipment &, supplies - Frequency – approximately 20%.
Bending, stooping and squatting - Frequency - approximately 10%.
Reaching, including above the head for supplies - Frequency - approximately 10%.
Pushing/Pulling: Frequency - approximately 20%.
Grip/hand dexterity; writing - Frequency - approximately 40%.
Climbing stairs - 0 - 10 times daily.

EDUCATION, TRAINING & EXPERIENCE

Current State of Arizona LPN License
Minimum 3 years working experience as LPN
Clinical experience with adult/ older adult populations within both the acute care setting as well as outpatient environments preferred
Demonstrated ability is use of Microsoft Office applications (eg. Word, Excel, Outlook, and PowerPoint) required .
Excellent customer service and communication skills required.
Knowledge of office phone systems required.
Experience with Electronic Medical Records
Current CPR Certification or ability to obtain within 30 days of hire

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Manager of Case Management is responsible for overseeing the operations of the Case Management team.

SPECIFICS

Direct, supervise, mentor and evaluate work activities of the entire Clinical Services department to achieve optimal efficiency, morale and employee/provider/member satisfaction. 
Operates in a fiscally responsible manner and identifies financial and other resources needed to achieve organizational goals/targets. 
Establish objectives and evaluative or operational criteria for departments they manage including Special Needs Population and Complex Care Management, Hospital/SNF Care Management 
Direct or conduct recruitment, hiring and training of personnel.  
Develop and implement organizational policies and procedures. 
Establish long-range objectives and specifying the strategies and actions to achieve them 
Ensures success of the Care Management program (Complex, Hospital and SNF) by overseeing and assisting with the ongoing development, implementation and advancement of the program. 
Facilitate resolution of applicable administrative challenges, problem-solve utilization-related concerns and promote open lines of communication with providers, their office staff, CLIENT personnel, and other internal and external customers. 
Conducts and participates in frequent utilization-related meetings and actively work with staff to educate and increase awareness/understanding of managed care principles as well as creative utilization-related decision making skills. 
Interacts proactively with Medical Director (s) and other applicable providers to problem solve and resolve utilization-related issues or concerns. 
Serves as a liaison between CLIENT Clinical Services division and contracted providers. Offers recommendations to applicable providers to improve patient care, decrease the frequency of emergency department visits, hospital readmission, home health modalities, etc., while maintaining high quality continuity of care. 
Maintain awareness of advances in health care, government regulations, health insurance changes, and financing options. 
Manage change in integrated health care delivery systems, such as work restructuring, technological innovations, and shifts in the focus of care. 
Prepare activity reports to inform management of the status and implementation plans of programs, services, and quality initiatives. 
Develop instructional materials and conduct in-service programs. 
Developing constructive and cooperative working relationships with others, and maintaining them over time. 
Special projects as assigned.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:
Work Position:

Sitting - 70% or more writing, typing and answering telephones.
Standing - less than 25%; at copier, filing, etc.
Walking - less than 25%

Body Movements:

Lifting 0-20-pounds; books, reams of paper, files, etc. 25%
Bending, stooping and squatting 25%
Reaching above head to 75 degrees less than 25%
Grip/hand dexterity; writing – over 50%
Climbing stairs 0-10 times per day

EDUCATION, TRAINING & EXPERIENCE

Graduate from an accredited Registered Nursing Program
Current unrestricted Arizona RN license
Minimum 10 years progressive management experience in health care and health care administration.
Working knowledge of Managed Care environment, use of resources and medical staff operations.
Ability to interact with all levels of management, physicians, staff, health plan representatives, and outside agencies/vendors.
Possess excellent communication, organizational and management skills.
Able to develop and maintain positive interpersonal relationships with co-workers.
Knowledge of computers, faxes, printers and all other office equipment.
Knowledgeable in MS Office Programs (i.e., Word, Excel, Outlook, Access and PowerPoint)
Current driver’s license and proof of insurance required.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
Client strives to be the network of choice for health plans and employers and the Manager of Provider Relations plays a critical role in ensuring high levels of provider satisfaction. This position manages the provider relations representatives. Assists the Director to manage the provider education and communications program to ensure CLIENT, health plan, and regulatory requirements are clearly communicated and met. Ensures providers are educated and aware of the CLIENT tools available for their use.

ESSENTIAL FUNCTIONS

Strengthens relationships with key providers and group practices.
Manage all aspects of Provider Relations and operations to support provider service, provider education, and product and market expansions.
Develops and trains staff to educate key individuals in Provider groups regarding new approaches, products, reimbursement methodologies, appropriate coding including risk scores, and policy or CLIENT standards changes. Creates efficiencies for offices decreasing the administrative hassle- develops educational programs for staff & providers.
Ensure an effective and timely provider communication and education function
Ensure contracted provider offices have frequent and regular interactions with the provider relations team. Track and report on office visit activity and identify issues requiring follow up. Coordinate timely responses on claims issues in collaboration with claims team. Escalate issues to supervisor requiring immediate intervention.
Conduct periodic office surveys on effectiveness of provider communications
Partner with HCC/STARS team to conduct effective practice management programs and education events.
Assist the Director of Provider Relations on maintaining the provider web page content to ensure information and resources are available to providers on a timely basis including updated provider directory
Assist marketing department with provider specific marketing initiatives
Assists the Director of Provider Relations with managing budget and forecasting to ensure departmental targets are established and maintained
Assist with development, implementation & management of community outreach strategies with network providers including a communication plan to keep them informed of current issues. Provides input to provider communication such as letters, presentations, and collateral materials as needed.
Develop strong relationships with outside partners, such as vendors and advisors, as well as internal partners, including department supervisors and co-executives.
Assist provider relations team in managing strong working relationships with all providers; this may include visits with providers as needed.
Assist with Formulating training programs; maintain efficient team structure and performance through analytics, processes and tools; maximizing new provider engagement; and working with the leadership team to develop plans to meet future needs.
Manages provider relations staff and redirects activities as necessary

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:
Work Position:

Sitting - 50% or more
SStanding - Approximately 25%
SWalking - Approximately 25%

Body Movements:

Lifting 0-25-pounds; books, supplies, files, etc. - Approximately 30%
Bending, stooping and squatting - Approximately 5%
Reaching above head to 75 degrees - Approximately 5%
Grip/hand dexterity; writing – Approximately 60%
Climbing stairs, one flight – approximately 5%

EDUCATION, TRAINING & EXPERIENCE

Bachelor’s degree or equivalent experience in Business Administration, Healthcare Administration or related field. MBA/MHA preferred. 5+ years of experience in customer service and provider relations in a health care or managed care environment.
Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
Excellent oral and written communication skills
Strong interpersonal and collaborative skills (experience working in a consensus building and matrix environments a plus).
Demonstrated experience and knowledge of CMS managed care contracting requirements

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
Under the direction of the VP of Clinical Services, the Social Worker understands the processes needed to ensure patient specific continuity of care during the transition to alternate levels of care. The SW is knowledgeable of development needs across all age groups including the elderly.

SPECIFICS

Partners with the Discharge Planner/Care Managers to work with the patient, family, and physician to facilitate a safe and effective care transition plan that meets the needs of each patient.
Using a variety of therapeutic modalities, the SW assists patients and families in the alleviation or resolution of social, financial, cultural and emotional problems and barriers related to the patients’ successful management of issues related to illness, health care and rehabilitation.
Provides psychosocial assessment, discharge planning, coordination, community referrals, and support/counseling.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:
Work Position:

Sitting - 70% or more writing, typing and answering telephones.
Standing - less than 25%; at copier, filing, etc.
Walking - less than 25%

Body Movements:

Lifting 0-20-pounds; books, reams of paper, files, etc. 25%
Bending, stooping and squatting 25%
Reaching above head to 75 degrees less than 25%
Grip/hand dexterity; writing – over 50%
Climbing stairs 0-10 times per day

EDUCATION, TRAINING & EXPERIENCE

Requires a Bachelor’s degree in Social Work. Master’s degree strongly preferred.
A minimum of 2 years Social Work experience in a healthcare setting
Experience in discharge planning in an acute care setting, complex psychosocial interventions, and well verse in community resource management
Ability to work independently and as a part of a team
Applicants must be detail oriented, able to function under pressure and able to re-prioritize tasks as needed.
Strong organizational skills and ability to handle multiple tasks simultaneously required
Excellent Customer service and communication skills, and comfort using the computer will contribute to the applicant’s success at performing the job requirements of this position.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Medical Director of HCC & Provider Education is a board-certified physician with strong clinical, administrative and management experience. They will have extensive knowledge of the CMS HCC-Risk Adjustment Model. This physician must be able to build and maintain strong working relationships with CLIENT providers in an attempt to ensure engagement and cooperation with HCC/STAR initiatives. The Medical Director will work closely with the supervisory and support staff as necessary to carry out objectives as well as develop and mentor both staff and the CLIENT provider network. This individual must work to achieve the goals of both the HCC and the Provider Education teams while maintaining a professional, positive and caring attitude at all times.

POSITION DUTIES & RESPONSIBILITES

Educates network providers about quality documentation, coding and billing in regards to CMS HCC Risk Adjustment Model and Quality STAR measures.
Mentors and develops the Associate Medical Director in support of all initiatives, expectations and goals related to the Home Wellness Program.
Directs and monitors the effectiveness, quality and compliance of the Home Wellness Program in conjunction with both STARS and HCC initiatives.
Manages, develops and conducts educational activities to grow and develop our provider physicians as well as staff.
Utilizes chart reviews in order to enhance provider knowledge and compliance
Utilizes reports provided to enhance educational opportunities’ and track provider progress
Serves as expert consultant and resource to CLIENT staff and providers in the network
Participates in creating and updating educational tools to be distributed to the network
Collaborates and supports members of multiple departments to enhance success
Demonstrates an in-depth knowledge of the provider network
Demonstrates ability to build strong, positive relationships with providers and office staff
Prioritizes duties to maximize efficiency and quality of work
Manages and promotes provider satisfaction through ensuring proactive service, support and education
Travels to off-site meetings
Actively identifies opportunities for process improvement and communicates best practices to improve overall efficiency.
Assists in the identification and development of standard department procedures
Participates in special projects and other duties as assigned

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:
Work Position:

Sitting - 70% or more
Standing - less than 25%
Walking - less than 25%

Body Movements:

Lifting 0-25-pounds; books, supplies, files, etc. - Approximately 30%
Bending, stooping and squatting - Approximately 5%
Reaching above head to 75 degrees - Approximately 5%
Grip/hand dexterity; writing – Approximately 60%
Climbing stairs, one flight – approximately 5%

EDUCATION, TRAINING & EXPERIENCE

Current Arizona license to practice medicine without restriction
Medical Doctorate or Doctor of Osteopathy degree required with appropriate Board Certification or qualification and level of expertise typically gained through five years experience in clinical practice.
Three to five years medical administrative experience preferably with emphasis on Managed Care members and Medicare rules and regulations.
Confidence in medical decision making and strong peer communication skills.
Ability to interact with all levels of management, physicians, staff, health plan representatives and outside agencies/vendors with a strong commitment to positively representing the Company.
Prior Experience with education and CMS HCC Risk Adjust Model preferred
Exceptional attention to detail and organizational skills required
Proficient in office equipment (computers, printers, etc.) and MS Office programs
Ability to maintain confidentiality; and ability to multi-task in a high stress environment
Excellent written and verbal communication skills

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Medical Director is a board certified physician with strong clinical, administrative and management experience. General duties include providing clinical expertise, medical interpretation and decisions about appropriateness of services, collaborate with Physician Advisors/Consultants, provide oversight to their review process, work collaboratively with Compliance and Quality on system initiatives and coordinate with physician leaders in counseling medical staff in a manner consistent with the medical staff bylaws. The UR Medical Director will work closely with the supervisory and support staff necessary to carry out the administrative functions. At this time, the Medical Director has no direct reports.

POSITION DUTIES & RESPONSIBILITES

Prior Authorization
Concurrent Review
Retrospective Review
Clinical Practice Guidelines
Medical Technology Assessment
Case Management/Care Coordination
Disease/ Chronic Illness Management
Drug Utilization Review
Data analysis and reporting
Preventive Health Program
Transplant Management
Strict adherence to production timeline
Special projects as assigned.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:
Work Position:

Sitting - 70% or more writing, typing and answering telephones.
Standing - less than 25%; at copier, filing, etc.
Walking - less than 25%

Body Movements:

Lifting 0-20-pounds; books, reams of paper, files, etc. 25%
Bending, stooping and squatting 25%
Reaching above head to 75 degrees less than 25%
Grip/hand dexterity; writing – over 50%
Climbing stairs 0-10 times per day

EDUCATION, TRAINING & EXPERIENCE

Current Arizona license to practice medicine without restrictions.
Medical Doctorate or Doctor of Osteopathy degree required with appropriate Board Certification or qualification and level of expertise typically gained through 5 years experience in clinical practice.
3 to 5 yrs medical administrative experience preferably with emphasis on Managed Care members and Medicare rules and regulations.
Experience in developing utilization protocols and supporting and motivating the clerical and nursing staff.
Confidence in medical decision making and strong peer communication skills.
Strong/creative UM experience and realistic approach to case management
Ability to research and integrate payor requirements in CLIENT processes.
Ability to interact with all levels of management, physicians, staff, health plan representatives, and outside agencies/vendors.
Possess excellent communication, organizational and influencing skills.
Knowledge of computers and experience using MS Office Programs (i.e., Word, Excel, Outlook, and PowerPoint)

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Medical Records & Data Coordinator is responsible for assisting with the daily operations of the HCC Data coordination. They are primarily responsible for ensuring that records retrieval and data entry are planned and executed in an organized timely manner to meet coding and audit project deadlines.

SPECIFICS

Assist with all daily operations and coordination of records retrieval and data entry for all coding and audit projects
Tracks retrieval and data entry productivity and quality.
Assists with the coordination of the records request process from acquiring member lists, scheduling with provider offices to actual retrieval and storage of records.
Maintain medical records folder.
Resolve issues with record retrieval.
Assists with the ESRD CMS Form 2728 identification and record retrieval process.
Assists in the coordination for all outpatient / hospital / institutional medical record retrieval process.
Assists with the development and maintenance of management reports to communicate process status and issues.
Supports policy and procedures related to record retrieval function.
Responsible for accuracy of data entry process from verification of demographic and claims information on EZCAP, actual qHMO data entry to communicating results to audit team.
Assiss with the development and maintenance of the data entry process/manual.
Participates as needed in training and educational opportunities.
Other duties and special projects as assigned.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:
Work Position:

Sitting - 70% or more writing, typing and answering telephones.
Standing - less than 25%; at copier, filing, etc.
Walking - less than 25%

Body Movements:

Lifting 0-20-pounds; books, reams of paper, files, etc. 25%
Bending, stooping and squatting 25%
Reaching above head to 75 degrees less than 25%
Grip/hand dexterity; writing – over 50%
Climbing stairs 0-10 times per day

EDUCATION, TRAINING & EXPERIENCE

High school diploma or equivalent required. College degree preferred.
2 years’ experience in professional office setting
Efficient and accurate computer skills—MS Excel and Word
Proven ability to effectively communicate and interact with all levels of the organization
Proven administration skills and ability to support and participate with meeting department goals
Ability to organize and prioritize workload and assist with supporting quality solutions
Detail oriented with strong analytical and interpersonal skills.
Current and valid Arizona drivers’ license and proof of insurance.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
Under the supervision of the Chief Medical Officer, the Nurse Practitioner will provide direct in-home patient care to improve outcome in quality, utilization, patient experience based on corporate goals and metrics. In collaboration with the physician of record and CLIENT team, the NP will provide direct patient care to CLIENT members in effort to reduce hospitalizations and readmissions and ER visits while improving quality of life. Utilize treatment guidelines (NCQA), evidence-based, consensus-based) to care for patients. The Nurse Practitioner will communicate and collaboratively manage the patients' care across all care providers, family, and caregivers. The NP will provide patient/unit of care education regarding chronic health conditions, Advance Directives, palliation, disease progression and end of life symptom management.

ESSENTIAL DUTIES & RESPONSIBILITIES

Patient visits in the patients’ residence (home, Extended Care Facility for the Elderly, or Skilled Nursing Facility) for the purpose of: Symptom management and assessment of other chronic illnesses at the request of the patient, family or a member of the interdisciplinary team. Visits to meet regulatory compliance with recertification prior to admission for 3rd benefit period (face-to- face) and Skilled Nursing Facility compliance. Assessment of conditions related to the terminal condition if discharge for extended prognosis is anticipated. Intervention for potential revocation of hospice services.
Collaborate and participate with RN Care Manager & Interdisciplinary Team in development and review of the comprehensive plan of care.
Participate in development of Palliative Care Program to meet the health care needs of identified population.v
Participate in development of the CLIENT Home Care Program to meet the health care needs of CLIENT members.
Maintain patient confidentiality and understand Compliancy such as HIPAA and FWA.
Attend staff meetings, promote departmental and organizational goals, and notify CMO per protocol when requesting time off.
Align and support Clinical Services metric goals of Beddays/K, Admits/K, Er visits/K, Re-admission rates, Access, Productivity, RAF, Star Measures, Patient satisfaction.
Other duties as directed.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:
Work Position:

Sitting - 60% or more writing, typing and answering telephones.
Standing - less than 25%
Walking - less than 25%

Body Movements:

Lifting - 0 - 60 pounds or more; maneuvering of patients, heavy equipment &, supplies - Frequency – approximately 20%.
Bending, stooping and squatting 25%
Reaching above head to 75 degrees less than 25%
Grip/hand dexterity; writing - Frequency - approximately 40%.Climbing stairs 0-10 times per day
Climbing stairs - 0 - 10 times daily.

EDUCATION, TRAINING & EXPERIENCE

Advance Degree Nursing/Advance Practice Nurse Certification
Unrestricted Arizona ANP license and DEA.
Five years of healthcare experience. Geriatric experience preferred. Program development experience is desirable.
Preferred experience in managed care environment/or a clear understanding of managed care systems.
Prior experience working with seniors and chronic disease management
Excellent assessment skills required; able to problem-solve with an awareness of level of care, intensity of service and severity of illness criteria
Ability to problem solve and prioritize dynamic patient conditions
Flexibility in their work environment as travel throughout the valley is required.
Willingness to help address the wrap-around issues of chronic disease management: patient education, psycho-social issues, family/care-provider issues, etc.
ACLS and BLS certifications required.
Is self-directed and must have excellent organizational and managerial skills.
Excellent interpersonal communication (written and verbal) skills.
Driving required. Current Arizona driver's license and proof of insurance.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Physician Liaison/Provider Educator is a medically trained individual with extensive knowledge of the CMS HCC-Risk Adjustment Model. This physician must be able to build and maintain strong working relationships with CLIENT providers in an attempt to ensure engagement and cooperation with HCC/STAR initiatives. They will work to achieve the goals of the Provider Education team while maintaining a professional, positive and caring attitude at all times.

ESSENTIAL DUTIES & RESPONSIBILITIES

Educates network providers about quality documentation, coding and billing in regards to CMS HCC Risk Adjustment Model and Quality STAR measures.
Utilizes chart reviews in order to enhance provider knowledge and compliance
Utilizes reports provided to enhance educational opportunities and track provider progress
Serves as expert consultant and resource to CLIENT staff and providers in the network
Participates in creating and updating educational tools to be distributed to the network
Collaborates and supports members of multiple departments to enhance success
Demonstrates an in-depth knowledge of the provider network
Demonstrates ability to build strong, positive relationships with providers and office staff
Prioritizes duties to maximize efficiency and quality of work
Manages and promotes provider satisfaction through ensuring proactive service, support and education
Travels to off-site meetings
Actively identifies opportunities for process improvement and communicates best practices to improve overall efficiency.
Assists in the identification and development of standard department procedures
Participates in special projects and other duties as assigned

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:
Work Position:

Sitting – 70% or more
Standing - less than 25%
Walking - less than 25%

Body Movements:

Lifting 0-25-pounds; books, supplies, files, etc. - Approximately 30%
Bending, stooping and squatting - Approximately 5%
Reaching above head to 75 degrees - Approximately 5%
Grip/hand dexterity; writing – Approximately 60%
Climbing stairs, one flight – approximately 5%

EDUCATION, TRAINING & EXPERIENCE

Must have graduated from medical school
Prior Experience with education and CMS HCC Risk Adjust Model preferred
Exceptional attention to detail and organizational skills required
Proficient in office equipment (computers, printers, etc.) and MS Office programs
Ability to maintain confidentiality; and ability to multi-task in a high stress environment
Excellent written and verbal communication skills
Must be able to interact with providers in a professional manner with a strong commitment to positively representing the company

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Provider Education Coordinator provides support and assistance to the HCC and Provider Education Departments. The Coordinator is responsible for internal and external provider reports and communication related to HCC and Provider Education. Responsible for the management and maintenance of the HCC AWV Access Database Tracker. Maintains a professional, positive and caring attitude at all times.

ESSENTIAL DUTIES & RESPONSIBILITIES

Manage and maintain HCC AWV Tracker and Education program
Creates processes and systems in order to maintain, monitor, track and report provider data.
Assists Medical Director of Provider Education with scheduling and preparation for on & off-site meetings w/various departments and/or provider offices as needed.
Serves as expert resource to team members in identifying and resolving provider education issues by demonstrating a high level of customer service.
Manages and promotes Provider Education, tracking and feedback through coordination of provider reports
Actively identifies opportunities for process improvement and communicates best practices to improve overall efficiency.
Assists in the identification and development of standard department procedures.
Participates in special projects and other duties as assigned.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:
Work Position:

Sitting - 70% or more
Standing - less than 25%
Walking - less than 25%

Body Movements:

Lifting 0-25-pounds; books, supplies, files, etc. - Approximately 30%
Bending, stooping and squatting - Approximately 5%
Reaching above head to 75 degrees - Approximately 5%
Grip/hand dexterity; writing – Approximately 60%
Climbing stairs, one flight – approximately 5%

EDUCATION, TRAINING & EXPERIENCE

Associates degree or relevant equivalent experience
Exceptional attention to detail and organizational skills required
Proficient in office equipment (computers, printers, etc.) and MS Office programs
Ability to maintain confidentiality; and ability to multi-task in a high stress environment.
Excellent written and verbal communication skills.
Must be able to interact with providers and team members in a professional manner with a strong commitment to positively representing the company
Prior experience in Provider Relations a plus

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Provider Network Manager is critical to the overall success of the company. Physicians (Primary Care and Specialist) value great service in all phases of provider recruitment, contracting, implementation and management of provider network. This includes contract negotiation, preparation, telephonic outreach and follow-up with providers, and securing contracts. Be relationship oriented, requiring someone with an outgoing personality, attention to detail, and firm understanding of the health care delivery system and contracting methods. Maintains a professional, positive and caring attitude at all times.

ESSENTIAL FUNCTIONS

Negotiates and completes contract rates and terms with individual physicians/medical groups and manages the day-to-day activities related to the negotiations, contracting and maintenance of the physician network
Responsible for the owning the contract throughout the contracting process, which includes: ensuring the contract rates and language are within approved company standards; ensuring implementation process and procedures are adhered to.
Accountable for contributing to the provider network development strategy as well as the successful on-boarding and orientation of new provider contracts
Engages in contracting methodologies and claims pricing/reimbursement strategies
Maintains detailed and accurate provider contact notes
Communicates to team and physician network of new or updated contracting methodologies, contract languages, and contacting systems, procedures, forms and manuals through staff meetings and verbal & written communication
Provides leadership to the provider relations staff whose focus is educating and maintaining a stable a comprehensive provider network through the development of strong business relationships with providers and practice managers.
Provides oversight and timely completion of assignments and suggesting approaches to resolution of issues.
Set objectives for provider relations network strategy, onsite provider visits, departmental goals and other annual requirements as well as maintaining and reporting provider relations dashboard metrics
Lead and manage staff to develop, manage and strengthen relationships with CLIENTs contracted providers and other network administrators
Oversee the quality and timeliness of CLIENT’s provider relations processes to ensure department standards are being met and to determine areas of potential improvement and/or enhancement
Consult and coordinate with various internal departments, providers as a representative of the area of responsibility
Extensive local travel to provider offices and events.
Other duties as assigned by management

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:
Work Position:

Sitting - 50% or more
Standing - Approximately 25%
Walking - Approximately 25%

Body Movements:

Lifting 0-25-pounds; books, supplies, files, etc. - Approximately 30%
Bending, stooping and squatting - Approximately 5%
Reaching above head to 75 degrees - Approximately 5%
Grip/hand dexterity; writing – Approximately 60%
Climbing stairs, one flight – approximately 5%

EDUCATION, TRAINING & EXPERIENCE

Associates degree or relevant equivalent experience
Prior experience with Network Contracting with physicians
Valid driver’s license and proof of insurance and good driving record
Proficient in office equipment (computers, printers, etc.) and MS Office programs (Word, Excel, PowerPoint, and Access); EZ-Cap experience a plus.
Excellent written and verbal communication skills.
Ability to maintain confidentiality
Ability to multi-task and prioritize in a high stress environment.
Knowledge of HMO, PPO, Medicare Risk and Indemnity products preferred; Accuracy and detail orientation (written and verbal)
Must be able to interact with providers in a professional manner with a strong commitment to positively representing the company

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Provider Relations Coordinator provides support and assistance to the Provider Relations Department. The Provider Relations Coordinator builds and maintains working relationships with CLIENT providers. Coordinates with network management to ensure provider changes are implemented and current. Responsible for internal and external provider reports and communication related to Provider Relations that includes maintenance and distribution of: provider manual, newsletters, fax blasts, etc. Maintains a professional, positive and caring attitude at all times.

POSITION DUTIES & RESPONSIBILITES

Demonstrates an in-depth knowledge of provider networks and providers’ needs; demonstrates ability to build strong, positive provider relationships; serves as expert consultant and resource to team members in identifying and resolving provider issues by demonstrating a high level of customer service.
Manages and promotes Provider satisfaction through ensuring proactive service, support and education.
Creates and maintains provider reference and training materials for use by providers and support staff on CLIENT website.
Coordinates Provider Network communication of critical information to providers, plan updates through email blasts, web site updates, newsletters and other communications; Responsible for verification, proofing and overall quality of Provider Network communications.
Assists in the development, coordination and implementation of provider related activities such as HCC Universities, Physician Dinners, Practice Manager Meetings, etc. that includes, creating/sending invitation, setting up venues, etc.
Review and maintenance of provider rosters; assists with re-credentialing activities for ensuring updated/timely credentialing of all contracted providers.
Participates in special projects, which may include HCC AWV program; Claims Issue Tracking Log, resolving provider’s telephonic contract inquiries.
Creates processes and systems in order to maintain, monitor, track and report provider data.
Assists Director of Provider Relations with scheduling on & off-site meetings w/various departments and/or provider offices as needed.
Actively identifies opportunities for process improvement and communicates best practices to improve overall efficiency.
Assists in the identification and development of standard department procedures.
Other duties as assigned.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:
Work Position:

Sitting - 70% or more
Standing - less than 25%
Walking - less than 25%

Body Movements:

Lifting 0-25-pounds; books, supplies, files, etc. - Approximately 30%
Bending, stooping and squatting - Approximately 5%
Reaching above head to 75 degrees - Approximately 5%
Grip/hand dexterity; writing – Approximately 60%
Climbing stairs, one flight – approximately 5%

EDUCATION, TRAINING & EXPERIENCE

Associates degree or relevant equivalent experience
rior Experience with Physician Network Contracting and Provider Relations
Proficient in office equipment (computers, printers, etc.) and MS Office programs
Ability to maintain confidentiality; and ability to multi-task in a high stress environment.
Excellent written and verbal communication skills.
Must be able to interact with providers in a professional manner with a strong commitment to positively representing the company

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Provider Relations Representative is critical to the overall success of the company. New and established participating providers value great service and maintenance throughout the term of the agreement. Service includes consistent telephonic, face-to-face and written communication and interaction in order to establish and retain positive and successful relationships with the participating provider network. The Provider Relations Representative shall be relationship oriented, requiring someone with an outgoing personality, attention to detail, and firm understanding of the health care delivery system. Maintains a collaborative, advising and attentive attitude at all times as well as represents CLIENT with a professional, well-dressed appearance.

POSITION DUTIES & RESPONSIBILITES

Assists with investigating and resolving administrative issues and concerns between CLIENT, provider network and the health plans.
Develops and maintains provider relationships and serves as the primary resource for internal staff and provider network by maintaining regular schedule of physician office visits to ensure open lines of communication between CLIENT and the provider network which also includes ensuring all providers receive timely and accurate information regarding organization initiatives, services, programs, policies and procedures, and quality measurements.
Ensures that CLIENT Administration are informed of any provider or health plan issues/concerns and supports CLIENT Administration by ensuring timely communication and resolution and also coordinates in-office support including, but not limited to: written and oral communication with providers, monthly preparation and distribution of packets, as applicable; Receive and respond to incoming phone calls and emails; and assists with verification of provider effective dates, termination dates, open/closed panel status, demographic information and health plan identification numbers.
Communicate and interact effectively with PCPs, Specialists and other contracted vendors/services through coordination, attendance at regular Office Manager meetings.
Ensures Provider Relations department goals are achieved as assigned, improve quality and business processes for assigned territory of responsibility.
Manages qHMO, AZ Connect, EZNet and other CLIENT systems user accessibility for the provider network.
Assists with marketing CLIENT by attending and participating in employer group events.
Coordinate the HCC program within the participating provider network by assisting with ICD and CPT coding for coding / billing as assigned.
Review & report statistical data for potential chart review / audit of participating provider network.
Maintain a structured process for quality of audits, tracking and trending including tracking provider network progress on HCC Concurrent program, and coordinate with HCC Department on further trainings.
Maintains detailed and accurate provider contact notes.
Significant travel in your personal vehicle to local provider offices and events.
Special projects and other duties as assigned by management.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:
Work Position:

Sitting - 50% or more
Standing - Approximately 25%
Walking - Approximately 25%

Body Movements:

Lifting 0-25-pounds; books, supplies, files, etc. - Approximately 30%
Bending, stooping and squatting - Approximately 5%
Reaching above head to 75 degrees - Approximately 5%
Grip/hand dexterity; writing – Approximately 60%
Climbing stairs, one flight – approximately 5%

EDUCATION, TRAINING & EXPERIENCE

Associates degree or relevant equivalent experience
Prior experience with Network Contracting with physicians
Proficient in office equipment (computers, printers, etc.) and MS Office programs (Word, Excel, PowerPoint, and Access); EZ-Cap experience a plus.
Excellent written and verbal communication skills.
Ability to maintain confidentiality
Ability to multi-task and prioritize in a high stress environment.
Ability to make decisions or solve problem by using logic to identify key facts, explore alternatives, and propose quality solutions
Ability to find, gather and collect information or data
Preferred knowledge of CPT, ICD, HCPCS, HCC coding; training available for the right candidate.
Knowledge of HMO, PPO, Medicare Risk and Indemnity products preferred; Accuracy and detail orientation (written and verbal)
Knowledge of qHMO, EZCap, NextGen preferred.
Must be able to interact with providers in a professional manner with a strong commitment to positively representing the company
Current unrestricted Arizona Driver’s license, reliable transportation and proof of insurance required.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The RN Care Coordinator – Automated Alerts is primarily responsible for monitoring and reviewing Automated Alerts alerts and identifying patients that may benefit from a care coordinated discharge directly from the hospital ED that is deemed an appropriate and safe alternative to a hospital observation and/or inpatient stay. This position will also be responsible for supporting the Clinical Services Department and include concurrent review activities as well as assisting the Care Management team. This individual will understand, exemplify and support CLIENT’S’s care coordination focused model.

POSITION DUTIES & RESPONSIBILITES

Performs an initial ED review utilizing the reference tool to identify diagnosis that have been identified as having a higher probability of rendering potential coordination of discharge from the ED in order to avoid unnecessary hospital admissions.
Reviews member’s history for utilization and past medical history; identifying “high utilizers”, and make recommendations on how to reduce recidivism, readmissions and unplanned transitions of care.
Reviews any documentation in the hospital’s EMR.
Speaks with hospital ED Case Manager, Nurse/Provider to introduce CLIENT’S model of care coordination.
Educates ED provider and staff on available options for safe discharge to avoid unnecessary hospital admission. Services include: transfer to SNF; home with home health/infusion; NP follow-up within 24 hours; intensive Case Management; Palliative Care or Hospice initiation.
Collaborates with CLIENT’S Medical Directors for assistance/support in speaking with ED providers as needed.
“Pushes” alerts to contracted hospitalist group.
Assists CLIENT’S SNF RN as needed to coordinate and ensure timely, safe transfers from ED to SNF.
Collaborates and performs timely communications with contracted vendor(s) to facilitate appropriate care coordination on members’ behalf.
Responsible for assessing and identifying members who are appropriate for palliative care or hospice conversion.
Substantiate by way of documented evidence that coordinated discharge intervention(s) directly resulted in a safe discharge from the ED that otherwise would have resulted in a hospital observation or admission encounter.
Responsible for clear, concise, concrete objective documentation of relevant communication with ED provider, staff and/or hospitalists of options to facilitate discharge from the ED.
Creates documentation that includes, but is not limited to: Date and time of initial and subsequent contact with ED staff, provider and hospitalist; Name, title and department of hospital staff that communications took place; Options presented for safe, appropriate discharge from ED to avoid unnecessary hospital admission or observation stay; If ED care coordination effort results in successful alternative safe discharge plan & specifics of discharge plan to be implemented; and if ED care coordination effort does not result in successful alternative safe discharge from the ED the RN shall document any and all options provided, discussions and reason stated by ED provider and/or hospitalist for not discharging member.
Identifies and submits to the Quality Department any potential quality issues for review as well as utilization issues.
Prepares daily, weekly, monthly, and quarterly reporting on Automated Alerts alerts received and outcomes associated with all ED care coordination efforts.
Participates in regularly scheduled Automated Alerts review meetings.
Back-up for reviewing concurrent hospital admissions, status changes and aberrant reviews. Collaborates with CLIENT’S Medical Directors for medical necessity determinations. Documents relevant changes in EZ Cap of member’s condition or status as they occur.
Participates in weekend, on-call coverage for Clinical Services Department.
Other duties as assigned.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:
Work Position:

Sitting - 70% or more writing, typing and answering telephones.
Standing - less than 25%; at copier, filing, etc.
Walking - less than 25%

Body Movements:

Lifting 0-20-pounds; books, reams of paper, files, etc. 25%
Bending, stooping and squatting 25%
Reaching above head to 75 degrees less than 25%
Grip/hand dexterity; writing - over 50%.
Climbing stairs 0-10 times per day

EDUCATION, TRAINING & EXPERIENCE

Valid and current, unrestricted AZ Registered Nursing license
Knowledge of Medicare, State and local managed care regulations, prior experience in Managed Care setting preferred.
Five years acute care or care management experience. Prior ER experience highly preferred.
Must have the ability to present clinical information in a manner that is accurate, concise and confident.
Demonstrates excellent communication skills in an effective, courteous and professional manner with all internal and external customers.
Demonstrates keen attention to detail.
Possesses ability to prioritize tasks, duties and projects based on organization competing demands.
Ability to work both independently and as part of a team, with minimal supervision.
Excellent customer service and communication skills, both oral and written.
Familiarity with electronic health records (EHR) systems.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Home Wellness Program (HWP) Registered Nurse (RN) is a licensed health professional who under the direction of the Home Wellness Program NP Supervisor, performs clinical and administrative duties that support the initiatives of Client HWP.

ESSENTIAL DUTIES & RESPONSIBILITIES

Conducts clinical nursing assessment of the patient, formulates nursing diagnosis by using the nursing process.
Refers patient concerns to appropriate level of care as identified based on clinical nursing assessment.
Performs telephone triage of patient to assess patient care needs based on acuity of patient concern
Identifies resources and assists with coordination of services in response to patient healthcare needs.
Under the guidance of the Home Wellness Program Supervisor collaborates with HWP team members utilizing both clinical and administrative skills.
Functions as internal resource for clinical and non-clinical team members to promote positive patient/ customer outcomes
Obtains and accurately tracks patient/ provider source list to promote coordination of visit schedule
Oversees the scheduling of patient home visits adhering to medical provider availability and aligning with patient residential geographical location
Conducts telephone calls to patients, providers, and other health care professionals and organizations in support of HWP initiatives
Conducts scheduling of patient visits that are conducted by HWP Medical Providers and Nursing Staff according to HWP established processes.
Demonstrates clear, concise, effective communication with HWP team members to ensure accurate scheduling procedures to support patient care outcomes.
Provides high quality customer service to both internal and external customers.
Ensures follow-through on patient/provider communications
Conducts patient visit reminder calls 24-48 hours in advance of scheduled “In Home” appointment upon request of HWP provider
Provides patient education regarding health promotion, chronic disease management, and annual screening examinations.
Conducts review of electronic health record and other appropriate data source (eg. QHMO,EzCAP,Business Solutions) to create patient clinical/demongraphic packet for HWP visit.
Conducts In-Home screening tests in to promote HEDIS / STAR measures.
Request hospital records for patient recent hospitalizations (past 3-6 months) if applicable.
Assist with coordination of patient referrals upon request of HWP medical provider
Receive and greet patients by answering phone calls, requests and/or forward message to appropriate HWP staff to promote customer satisfaction/problem resolution.
Demonstrates and adheres to HIPAA polies and procedure that include, yet may not be limited to the following functions:
Patient telephone encounters utilizing two (2) patient identifiers
Requesting, transmitting, handling patient Protected Health Information
Participates in the interview and selection process of HWP staff when
Participates in the orientation and training of HWP clinical and non-clinical staff
Performs other duties as assigned within Registered Nurse scope of practice

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:

Office & Clinic setting; prolonged sitting and standing.
Potential exposure to infectious disease, must use universal precautions.

Body Movements:

Lifting - 0 - 60 pounds or more; maneuvering of patients, heavy equipment &, supplies - Frequency – approximately 20%.
Bending, stooping and squatting - Frequency - approximately 10%.
Reaching, including above the head for supplies - Frequency - approximately 10%.
Pushing/Pulling: Frequency - approximately 20%.
Grip/hand dexterity; writing - Frequency - approximately 40%.
Climbing stairs - 0 - 10 times daily.

EDUCATION, TRAINING & EXPERIENCE

Current and valid State of Arizona RN License
Bachelor’s Degree in Nursing preferred
Minimum 3 years working experience as RN
Clinical experience with adult/older adult populations within both the acute care setting as well as outpatient environments preferred
Demonstrated ability is use of Microsoft Office applications (eg. Word, Excel, Outlook, and PowerPoint) required .
Excellent customer service and communication skills required.
Knowledge of office phone systems required.
Experience with Electronic Medical Record
Current CPR Certification or ability to obtain within 30 days of hire

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Medical Records Technician performs medical records functions including but not limited to: Retrieval and electronic filing of medical records.

SPECIFICS

Utilizes a variety of EMR systems with competence to access patient records, demographic information, and to problem-solve patient identification, and other relevant investigative issues.
Travels to medical offices to retrieve medical records; works closely with medical office staff to facilitate retrieval according to their established and required protocols.
Scans/transfers files within expected timeframes while observing HIPAA-compliant processes.
Maintains equipment according to guidelines, and communicates all issues to supervisor.
Works with other departments as directed in a collaborative effort to maintain all stored medical records.
Reviews medical records for accuracy and completeness.
Organizes and evaluates both physical and electronic versions of medical records.
Performs other duties as assigned.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:

Some equipment lifting and transport is required.
Work independently and within time constraints.
Extensive travel outside of the office.

Work Position:

Sitting - 60% or more writing, typing and answering telephones.
Standing - less than 20%; at copier, filing, etc.
Walking - less than 20%

Body Movements:

Lifting 20-30 pounds; Approximately10% of day
Bending, stooping and squatting 10%
Reaching above head to 75 degrees approximately 10%
Grip/hand dexterity; writing – Approximately 85% of day
Climbing stairs 0-10 times per day

EDUCATION, TRAINING & EXPERIENCE

High school diploma or equivalent required
Previous experience in a medical group/office preferred.
Intermediate to advanced computer skills. Working knowledge of scanning and medical technology.
Ability to file accurately using electronic, alphabetical, numeric, and color-coded systems.
Detail-oriented with good organizational skills
Good inter-personal communication skills
Current Arizona Driver’s license and proof of insurance required.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Sr. Provider Relations Coordinator provides support and assistance to the Provider Relations Department. The Sr. Provider Relations Coordinator works closely with PR Representatives in communicating and maintaining working relationships with CLIENT participating providers. Coordinates with network management to ensure provider changes are implemented and current. Responsible for internal and external provider reports and communication related to Provider Relations that includes maintenance and distribution of: provider manual, newsletters, fax blasts, etc. Maintains a professional, positive, and caring attitude at all times.

POSITION DUTIES & RESPONSIBILITES

Demonstrates an in-depth knowledge of provider networks and providers’ needs; demonstrates ability to build strong, positive provider relationships; serves as expert consultant and resource to team members in identifying and resolving provider issues by demonstrating a high level of customer service.
Manages and promotes Provider satisfaction through ensuring proactive service, support, and education.
Manage calendars to ensure no overlaps
Manages incoming faxes and ensures that they are distributed to appropriate departments.
Maintains provider reference and training materials for use by providers and support staff on CLIENT website.
Responsible for verification, proofing and overall quality of Provider Network communications. Coordinates distribution of such communication to providers; health plan updates through email blasts, web site updates, newsletters and other forms of communications.
Assists in the coordination, and implementation of provider related activities such as Office Manager Meetings, Physician Dinners, and HCC Universities, etc. that includes, sending invitation, setting up venues, processing payments, etc.
Review and maintain updated provider rosters; assists with re-credentialing activities for ensuring updated/timely credentialing of all contracted providers.
Participates in special projects, which may include HCC AWV program and Claims Issue Tracking Log.
Supports designated departments in maintaining, monitoring, tracking, and reporting of provider data.
Audit of CLIENT systems to include but not limited to AZ Connect, qHMO, EZ Net, and Business Solutions to ensure data accuracy.
Audit of visitation tracker on a regular basis to verify accuracy of reporting.
Audit PR Rep Assignment Log on a bi-weekly basis to verify current PCP Membership, Department Engagement level, current PR Rep assignment and all relevant data.
Complete timely Provider Relations entries into Business Solutions to ensure adequate communication between different departments.
Assists Director of Provider Relations and/or Provider Relations Manager with scheduling on & off-site meetings with provider offices and/or various departments as needed.
Actively identify opportunities for process improvement and communicate best practices to improve overall efficiency to support the PR Department.
Assists in the identification and development of standard department procedures.
Provide weekly, monthly, quarterly, and annual reports to the Provider Relations Director which include but are not limited to AZ Connect Activity, Monthly PR Visits, Claim Denied for No Auth, OON Lab, etc.
Review PR Representative calendars to ensure coordination of timely report preparation
Frequent communication between Coordinators to ensure thorough completion of daily task expectations.
Assists the Provider Relations Manager in developing and organizing monthly packet for review and approval by the Provider Relations Director.
Other duties as assigned.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:
Work Position:

Sitting - 70% or more
Standing - less than 25%
Walking - less than 25%

Body Movements:

Lifting 0-25-pounds; books, supplies, files, etc. - Approximately 30%
Bending, stooping and squatting - Approximately 5%
Reaching above head to 75 degrees - Approximately 5%
Grip/hand dexterity; writing – Approximately 60%
Climbing stairs, one flight – approximately 5%

EDUCATION, TRAINING & EXPERIENCE

Associates degree or relevant equivalent experience
Prior Experience with Physician Network Contracting and Provider Relations
Proficient in office equipment (computers, printers, etc.) and MS Office programs
Ability to maintain confidentiality; and ability to multi-task in a high stress environment.
Excellent written and verbal communication skills.
Must be able to interact with providers in a professional manner with a strong commitment to positively representing the company

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Care Manager is responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation for members. The Care Manager will assess and develop a care plan in collaboration with the member, primary care physician, social worker, and other health care practitioners. The goal of the Care Manager is to effectively manage members to assure the appropriate level of care is provided, to prevent inpatient re-admissions and ensure that the members’ medical, environmental and psychosocial needs are met over the continuum of care in the least restrictive environment.

SPECIFICS

Keeps member/caregivers informed and requests, if necessary, further assistance when needed.
Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.
Functions as liaison between administration, members, physicians and other healthcare providers.
Interacts professionally with member/caregiver/physicians.
Performs assessment/reassessment of members to facilitate appropriate discharge plan.
Participates in the interdisciplinary team, along with physicians, social worker and other health care practitioners to develop individualized care plan.
Identifies the appropriate members to participate in the interdisciplinary case rounds. Prepares the necessary summary information to present to the team.
Documents member assessment and reassessment, as regards to discharge planning and other pertinent information in the member’s medical record in accordance with the PIP Charting methodology, nursing standards, and company policies and procedures.
Educates the member/caregiver on the transition process and how to reduce unplanned transitions of care.
Manages transition of care at every level ensuring that the Plan of Care moves with the member and updates/modifies the care plan as the member’s health care status changes.
Communicates appropriately and clearly with physicians, hospital discharge planners and Prior-Authorization nurses
Identifies and addresses psychosocial needs of the member and facilitates consultations with social worker or MHN, as necessary.
Identifies community resources to address needs not covered by the member’s benefit plan, and coordinates member benefits as needed, with the health plan.
Participates in the efficient, effective and responsible use of resources such as supplies and equipment.
Ability to collaborate and communicate with all members of the healthcare team (prior authorizations, PCP/SPC, social services and complex care coordinators) to coordinate the continuum of care of developing plans for management of each case.
Responsible for the identifying members that are appropriate for hospice conversion or palliative care.
Other duties including on-call duties as assigned.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:
Work Position:

Sitting - 70% or more writing, typing and answering telephones.
Standing - less than 25%; at copier, filing, etc.
Walking - less than 25%

Body Movements:

Lifting 0-20-pounds; books, reams of paper, files, etc. 25%
Bending, stooping and squatting 25%
Reaching above head to 75 degrees less than 25%
Grip/hand dexterity; writing – over 50%
Climbing stairs 0-10 times per day

EDUCATION, TRAINING & EXPERIENCE

Current AZ RN license without restrictions with a willingness to learn the required duties for this position.
Valid AZ Driver’s license.
3 years acute care or Care management experience.
2-3 years of utilization or HMO experience preferred.
Typing 40 words per minutes with accuracy.
Knowledge of computers, faxes, printers and all other office equipment.
Knowledgeable in MS Office Programs (i.e., Word, Excel, Outlook, Access and PowerPoint)
Ability to work independently and as part of a team.
Ability to be detail-oriented, able to function under pressure and able to re-prioritize tasks as needed.
Excellent customer service and communication skills and comfort using the computer.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
This individual will oversee key areas/departments including HCC, Home Wellness Program, and Clinical Documentation Improvement. The Senior Director is responsible for organizing, planning, directing and managing activities of assigned areas to ensure that high quality care is effectively and efficiently provided. This individual demonstrates personal initiative, team spirit, and service orientation while maintaining a positive, caring, professional attitude. The Senior Medicare Risk Adjustment and Home Wellness Program employee is a key leader at Client and must ensure that they exemplify Client’s values and support the mission and vision of the organization.

SPECIFICS

Improve the operational systems, processes and policies in support of organizations mission specifically, support better management reporting, information flow and management of business process and organizational planning
Oversee the development and implementation of policies and procedures pertinent to the effective and efficient operation of the HCC, Home Wellness Program and Clinical Documentation Improvement in alignment with the Company’s objectives.
Develop strong relationships with outside partners, such as vendors and advisors, as well as internal partners, including department supervisors and co-executives.
Collaborate with Customer Service, Provider Education, STARS and Provider Relations on escalated issues and trend analysis of provider and member complaints and process improvements.
Works closely with the corporate partners in consultation on all matters of significance, including but not limited to, contract rate negotiations, payer relations, contract performance, and any other matters at their discretion.
Champion, enforce and comply with Company policies, procedures and Standards of Business Ethics and Conduct
Identify and drive client revenue generating projects and operational improvement projects
Enhance operational processes and tools and standardize efficient and effective practices across the division
Present key metrics to executive management with explanation of variances
Build, coach and develop talent within the CLIENT management team.
Administer hiring, promotions, bonuses and wage adjustments within corporate guidelines

HCC

Manage the development and implementation of programs designed to both appropriately capture all patient’s diagnoses, and assure appropriate documentation in the patient chart. Partners with clinician leadership to ensure the clinical aspects of HCC and Clinical Quality programs and best practices are communicated to all.
Oversees the implementation of Risk Adjustment Management Programs related to complete capture of HCC Diagnosis codes, appropriate documentation of conditions based on claim record and/or member’s medical record.
Develops, interprets and implements policies and procedures to create and maintain an effective managed care program with maximum reimbursement rates.
Collaborate with multiple departments to develop a physician incentive program.
Identify and drive client revenue generating projects and operational improvement projects.
Develop reports to enhance provider educational opportunities and track provider progress.
Develop system for monitoring and tracking progress and processes for escalating potential issues.
Monitor marketplace evolution and process trends to drive innovation
Ensures effective and timely provider communication and education function
Stay abreast of compliance hot topics

Home Wellness Program:

Coordinates, oversees, and completes all aspects of Home Wellness Program projects and initiatives while managing staff’s (Both NPs and Coordinators) during day-to-day operations.
Manages progress and efficiencies of HWP projects and initiatives.
Identify opportunities and provides guidance and suggestion for quality performance improvements.
Analyze data collection for patterns and trends to identify opportunities to improve documentation and processes.

Clinical Documentation Improvement/Provider Education

Educate Network Providers about quality documentation, coding, and billing in regards to CMS HCC risk adjustment model and quality STARS measure.
Utilize chart reviews in order to enhance provider knowledge and compliance.
Utilize reports to enhance provider educational opportunities and track provider progress.
Manages and promotes provider satisfaction through ensuring proactive services.
Support, develop and educate.
Actively identifies opportunities for process improvement and communicates best practices to improve overall efficiency.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:
Work Position:

Sitting - 70% or more
Standing - less than 25%
Walking - less than 25%

Body Movements:

Lifting 0-25-pounds; books, supplies, files, etc. - Approximately 30%
Bending, stooping and squatting - Approximately 5%
Reaching above head to 75 degrees - Approximately 5%
Grip/hand dexterity; writing – Approximately 55%
Climbing stairs, one flight – approximately 5%

EDUCATION, TRAINING & EXPERIENCE

A bachelor’s degree required, MHA or MBA preferred.
7-10 years of experience in Healthcare required.
Prior experience overseeing Provider Relations, Contracting and/or HCC/RAF programs
Demonstrates a mastery in outcomes analysis and reporting.
Excellent oral and written communication skills
Ability to interact with all levels of staff and interdisciplinary teams to achieve established goals.
Detail oriented with strong analytical and interpersonal skills.
Relies on experience and judgment to achieve goals.
Excellent critical thinking skills.
Flexible and able to handle and prioritize multiple tasks and function under pressure.
Strong Computer knowledge: Microsoft Office (Outlook, Word, Excel, Power Point). Experience with EzCAP a plus.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
To Review, assist, and communicate with the STARs team, administration, providers, and members regarding HEDIS/STARs program on behalf of Client.

SPECIFICS

Review retrieved medical records to identify, document, and upload HEDIS/STAR measures that substantiate compliance into necessary database(s)
Review physicians’ reports to analyze HEDIS/STAR measures needed in order to assist in the individualize request for medical records
Assists in collaboration for process development to increase member compliance with HEDIS/STAR measures
Assist STAR’s with spreadsheet processing of weekly reports to management, providers, and other inter-departmental departments
Use excellent customer service skills to contact members by phone and mail in efforts to educate and assist members with completing HEDIS/STAR measure
Prepare for three month auditing period with Health Net and/or other insurances Review annual updates on HEDIS measures and act as a resource for NCQA Standards relating to HEDIS
Support and maintain an environment which fosters high customer and employee satisfaction and quality service
Perform other duties as assigned

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.
Demonstrated personal initiative, team spirit, and service orientation are vital

PHYSICAL DEMANDS/WORK ENVIRONMENT:

Some equipment lifting and transport is required
Work independently and within time constraints
Travel outside of the office

Work Position:

Sitting – 60% or more
Standing – 20% or more
Walking – 15% or more
Driving – 5% or more

Body Movements:

Lifting 0-10 pounds; documents, supplies, files – Frequency - approximately 10%
Bending, stooping and squatting – Frequency - approximately 15%
Reaching above head to 75 degrees – Frequency - approximately 15%
Grip/hand dexterity – Frequency - approximately 70% of day
Climbing stairs 0-10 times per day

EDUCATION, TRAINING & EXPERIENCE

High School diploma required. College degree preferred
Arizona Medical Assistant certification preferred
Minimum 1 year experience in healthcare or managed care setting with responsibility for systems and/or projects
Knowledge of qMetrics, EZCap & NextGen preferred
Ability to find, gather and collect information or data
Excellent written and oral communication skills
Ability to work independently once oriented to routine and process
Intermediate level proficiency with Microsoft Office applications including Word, Excel, Power Point, and Access

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Stars Director is responsible for the management of CLIENT Stars Department daily operations and coordination of the quality measure performance initiatives. The Director will serve as an expert resource for quality measure specifications and will provide educational updates to physician office staff and CLIENT team members. The overarching function of the Director, Stars is to oversee team member outreach efforts, provide ongoing data evaluation and progress reports to physician offices and problem solve to resolve any discrepancies that have been identified. The Director of Stars will work under the direction of the CMO.

SPECIFICS

Provide Continuous monitoring of quality measure date (numerators and denominators), identify irregularities and resolve with input from the VP, Value Based Care Initiatives & Network Management.
Evaluates quality measure data information and assists in establishing priorities for outreach efforts so that goals are achieved.
Directs and supervises CLIENT internal outreach team in implementation of patient directed outreach efforts.
Supervises data reporting process and distribution to provider offices and CLIENT teams.
Assist in the development of provider and team directed education regarding quality measure specification details, changes and updates.
Support the development and implementation of new programs that may be innovative in their approach to maximize success with member outreach, closure of quality measure gaps and member satisfaction scores (HOS, CAHPS).
Other duties as assigned.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.

PHYSICAL DEMANDS/WORK ENVIRONMENT:

Some equipment lifting and transport is required
Work independently and within time constraints
Travel outside of the office

Work Position:

Sitting - 70% or more writing, typing and answering telephones.
Standing - less than 25%; at copier, filing, etc.
Walking - less than 25%

Body Movements:

Lifting 0-20-pounds; books, reams of paper, files, etc. 25%
Bending, stooping and squatting 25%
Reaching above head to 75 degrees less than 25%
Grip/hand dexterity; writing – over 50%
Climbing stairs 0-10 times per day

EDUCATION, TRAINING & EXPERIENCE

High school diploma or equivalent required. Bachelors degree preferred.
Certification from an accredited coding program required. CPMA and/or CRC preferred.
2 years’ experience in coding
One year experience in a supervisory role preferred.
Knowledge of ICD-9 and CPT codes required.
Strong computer skills
Ability to effectively interact at all levels of the organization.
Able to lead staff to achieve goals
Current Arizona drivers license and proof of insurance.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Telephonic Hospital Concurrent Review Nurse telephonically concurrently monitors and reviews all member utilizations for medical appropriateness, makes recommendations for alternative levels of care, identifies potential barriers or delays in service and facilities discharge planning activities. Additionally, the Telephonic Hospital and Complex Care Manager will continue to telephonically monitor and manage the patient post-hospitalization until they can be transitioned to a lower level of Care management.

SPECIFICS

Telephonically performs the initial inpatient admission medical necessity reviews as well as all ongoing concurrent utilization and quality screening reviews for all, in network, hospitalized patients using industry recognized criteria and guidelines.
Communicates frequently with the Hospitalist(s), Admitting Physician(s) and Specialty Provider(s) in order to facilitate timely consultations, solidify the plan of care, clarify the current level of care and/or problem-solve any potential obstacle to a safe discharge.
Telephonically monitors all physician ordered clinical activities, and anticipates delays in physician decision making which, without immediate intervention, might result in delays(s) of care as well as unnecessarily prolonging a hospitalization.
When avoidable delays are identified, initiates immediate corrective action(s) including, but not limited to, direct communication with Hospitalist(s), Admitting Physician(s) and Specialty Provider(s) in an effort to facilitate care. When applicable, seeks immediate intervention by the Medical Director when unable to impact physician decision-making regarding potential delays in service.
Accomplishes discharge screening on all admissions, and when appropriate, makes recommendations for alternative to lower levels of care to the Hospitalist(s), Admitting Physician(s) and Specialty Provider(s) regarding discharge planning and dispositions.
Ensures timely and safe discharges and/or SNF transfers for medically stable patients, including but not limited to securing that all needed DME and Home Health needs are in place.
Updates EzCap and/or the Daily Hospital Log and reports significant/relevant changes in patient’s condition or status, as they occur. When applicable, will also provide timely alerts to all other applicable Client Programs or Providers of such status or disposition changes.
Initiates and ensures compliance with acquiring signed denial notifications from the patient or their legal representative, in accordance with both State and Federal regulatory guidelines.
Continues to telephonically follow and Care management those complex members who require further post-hospitalization monitoring until they can be transitioned to a lower level of Care management.
Actively participates on the Client Inter-Disciplinary Care team. Provides regular clinical update(s) to team members of both hospitalized as well as those complex members being telephonically managed post-discharge.
Ensures that the Referral Department receives sufficient supporting documentation so that all requests for post-hospital specialty care and/or services can be processed timely, completely and without delay.
Identifies and submits to the Quality Improvement Committee any potential or actual quality issues for their review as well as utilization issues; e.g., over/under utilization, delay of service issues, etc.
Participates and equally shares in after-hour call coverage for Clinical Services.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.

PHYSICAL DEMANDS/WORK ENVIRONMENT:
Work Position:

Sitting - 70% or more writing, typing and answering telephones.
Standing - less than 25%; at copier, filing, etc.
Walking - less than 25%

Body Movements:

Lifting 0-20-pounds; books, reams of paper, files, etc. 25%
Bending, stooping and squatting 25%
Reaching above head to 75 degrees less than 25%
Grip/hand dexterity; writing – over 50%
Climbing stairs 0-10 times per day

EDUCATION, TRAINING & EXPERIENCE

Current unrestricted AZ Nursing license.
Knowledge of Medicare, state, and local managed care regulations, prior experience in Managed Care setting preferred.
3 years acute care or care management experience, prior ER or ICU or other relevant clinical role requiring quick critical thinking experience preferred.
Must have the ability to present clinical information both accurately and confidently as well as communicate effectively with all levels of internal staff and external customers in a professional manner.
Ability to be detail-oriented, able to function under pressure and able to re-prioritize tasks as needed.
Ability to work both independently and as part of a team, with a willingness to perform all required duties for this position.
Excellent customer service and communication skills, both oral and written, and comfort using the computer with accuracy.
Familiarity with Electronic Health Records systems, preferably NextGen and/or EzCap.
Driving required. Current and unrestricted AZ driver license with proof of insurance required.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

SUMMARY:
The Vice President of Clinical Services is responsible for overseeing the operations of the Clinical Services Department.

SPECIFICS

Direct, supervise, mentor and evaluate work activities of the entire Clinical Services department to achieve optimal efficiency, morale and employee/provider/member satisfaction.
Operates in a fiscally responsible manner and identifies financial and other resources needed to achieve organizational goals/targets.
Establish objectives and evaluative or operational criteria for departments they manage including Special Needs Population and Complex Care Management, Hospital/SNF Care Management
Direct or conduct recruitment, hiring and training of personnel.
Develop and implement organizational policies and procedures.
Establish long-range objectives and specifying the strategies and actions to achieve them
Ensures success of the Care Management program (Complex, Hospital and SNF) by overseeing and assisting with the ongoing development, implementation and advancement of the program.
Facilitate resolution of applicable administrative challenges, problem-solve utilization-related concerns and promote open lines of communication with providers, their office staff, CLIENT personnel, and other internal and external customers.
Conducts and participates in frequent utilization-related meetings and actively work with staff to educate and increase awareness/understanding of managed care principles as well as creative utilization-related decision making skills.
Interacts proactively with Medical Director (s) and other applicable providers to problem solve and resolve utilization-related issues or concerns.
Serves as a liaison between CLIENT Clinical Services division and contracted providers. Offers recommendations to applicable providers to improve patient care, decrease the frequency of emergency department visits, hospital readmission, home health modalities, etc., while maintaining high quality continuity of care.
Maintain awareness of advances in health care, government regulations, health insurance changes, and financing options.
Manage change in integrated health care delivery systems, such as work restructuring, technological innovations, and shifts in the focus of care.
Prepare activity reports to inform management of the status and implementation plans of programs, services, and quality initiatives.
Develop instructional materials and conduct in-service programs.
Developing constructive and cooperative working relationships with others, and maintaining them over time.
Special projects as assigned.

ORGANIZATIONAL & PROFESSIONAL RESPONSIBILITIES

Proactively support and practice Client’s mission, vision and values.
Follow Employee Handbook guidelines and Client policies and procedures.
Promote departmental and organizational goals.
Embody Client’s values of Integrity, Quality, Service Excellence & Teamwork each and every day.
Maintain confidentiality at all times in compliance with Client policy and HIPAA requirements.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy.
Follow established dress code.
Be courteous, flexible and adaptable.
Know and follow applicable safety standards, policies and procedures.

PHYSICAL DEMANDS/WORK ENVIRONMENT:
Work Position:

Sitting - 70% or more writing, typing and answering telephones.
Standing - less than 25%; at copier, filing, etc.
Walking - less than 25%

Body Movements:

Lifting 0-20-pounds; books, reams of paper, files, etc. 25%
Bending, stooping and squatting 25%
Reaching above head to 75 degrees less than 25%
Grip/hand dexterity; writing – over 50%
Climbing stairs 0-10 times per day

EDUCATION, TRAINING & EXPERIENCE

Graduate from an accredited Registered Nursing Program
Current AZ RN license without restrictions.
Master Degree (MBA/MHA preferred)
Minimum 10 years progressive management experience in health care and health care administration.
Working knowledge of Managed Care environment, use of resources and medical staff operations.
Ability to interact with all levels of management, physicians, staff, health plan representatives, and outside agencies/vendors.
Possess excellent communication, organizational and management skills.
Able to develop and maintain positive interpersonal relationships with co-workers.
Knowledge of computers, faxes, printers and all other office equipment.
Knowledgeable in MS Office Programs (i.e., Word, Excel, Outlook, Access and PowerPoint)
urrent driver’s license and proof of insurance required.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

24 Hour Careline: 480-494-2466

STRONG
FOCUS

DEMONSTRATING

A Brighter Way for Brighter Days

"USHS offers top industry leadership, competitive benefits with a superb opportunity to learn and advance within healthcare's most fascinating area of growth."

OUR APPROACH
TO POST-ACUTE

A powerful services network able to move members and their providers through the post-acute care continuum and back into a stable medical home environment.

Local Services

Join Our Team

Available Positions

Now hiring for:

Contact

Copyright © 2018, USHS Us Health Systems

24 Hour Careline: 480-494-2466

STRONG FOCUS

DEMONSTRATING

A Brighter Way for Brighter Days

"USHS offers top industry leadership, competitive benefits with a superb opportunity to learn and advance within healthcare's most fascinating area of growth."

OUR APPROACH TO POST-ACUTE

A powerful services network able to move members and their providers through the post-acute care continuum and back into a stable medical home environment.

Local Services

Join Our Team

Available Positions

Now hiring for:

Contact

Copyright © 2018, USHS Us Health Systems

STRONG
FOCUS

OUR APPROACH
TO POST-ACUTE