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To list your job openings for FREE, e-mail them to B.J. Taylor, with "job listing" in the subject line. Job listings are in chronological order with the most recent posted first. Openings listed
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BlueCross and BlueShield of Tennessee,Medical Case Manager – Nashville
Confidential Company, Billing And Collection Department Manager
- The Burchfield Group, Sales Coordinator
- Sisters of Mercy Health System, Sr. Clinical Manager
- Blue Shield of California, Regional Medical Director – Northern California
- Blue Cross Blue Shield of Massachusetts,
Joint Enterprise (PDP) Product Manager - Employees Retirement System of Texas,
Contract Administrator - BlueCross and BlueShield of Tennessee,
Principal Consultant Finance Technology - Major Insurance Company, Senior Executive Level Position – Marketing Unit
- Integrated Solutions Health Network, LLC,President and CEO
- EMD Serono, Inc., Regional Account Manager Northeast
- Confidential Managed Health Insurer, Compliance Auditor
- Confidential Managed Health Insurer,Product Specialist, Medicare
- CatalystRx, Quality Assurance Pharmacist
- CatalystRx, Clinical Manager
- Confidential Clinical Informatics Company, Senior Sales Executives
- Coulter & Associates, Compliance Consultant
- Security Health Plan, Chief Financial Officer
- Confidential Health Plan, Regional Medical Director
- Coram Specialty Infusion, Regional Director of Managed Care
- Confidential Managed Care Organization, Medical Director
- Confidential Managed Care Organization, Medical Director
- Company Confidential, Managed Care Medical Directors
- HealthPartners, Medication Therapy Management Pharmacy Program Manager
- Employee Health Insurance Management, Inc,
Agency Administration Account Manager - Blue Cross and Blue Shield Health Plan,
Director, Brand Strategy and Marketing - The Burchfield Group, Senior Claims Auditor
- EMD Serono, National Account Manager
- Employee Health Insurance Management, Agency Administration Account Manager
- Health Plus, Contracts Specialist
- Health Plus, Internal Compliance Auditor
- Health Plus, Sr. Auditor, Compliance Audit Unit
- Qualis Health, Director, Business Development
- AvMed Health Plan, Chief Information Officer
- Partners Healthcare System, Inc., Financial Analyst
- KHR, Manager of Utilization Management
- CatalystRx, Executive Director, Client Services
BlueCross and BlueShield of Tennessee
Medical Case Manager – Nashville
Nashville, Tenn.
This position is accountable for promoting interdependent collaboration with the member, physician/primary care manager, family and other members of the health care or case management team. To accomplish this collaboration, the case manager will assess, implement, monitor, and evaluate available resources in an effort to promote quality, cost effective outcomes while meeting the individual's health needs. The case manager identifies appropriate providers and facilities in an effort to improve or maintain the social, emotional, functional and physical health status of the client, as well as enhance the coping skills of the family or other caregiver. Position has the opportunity to work a four day compressed work week once fully trained.
Job Duties & Responsibilities:
- Conduct a thorough and objective evaluation of the client's current status including physical, psychosocial, environmental, financial, and health status expectation.
- As a client advocate, seek authorization for case management from the recipient of services (or designee).
- Assess resource utilization and cost management; the diagnosis, past and present treatment; prognosis, goals (short- and long-term).
- Identify opportunities for intervention.
- Set goals and time frames for goals appropriate to individual.
- Arrange, negotiate fees for, and monitor appropriate cases and services for the client.
- Maintain communication and collaborate with patient, family, physicians and health team members, and payer representatives.
- Compare the client's disease course to established pathways to determine variances and then intervene as indicated.
- Routinely assess client's status and progress; if progress is static or regressive, determine reason and proactively encourage appropriate adjustments in the care plan, providers and/or services to promote better outcomes.
- Establish measurable goals that promote evaluation of the cost and quality outcomes of the care provider.
- Report quantifiable impact, quality of care and/or quality of life improvements as measured against the case management goals.
- Participate in Inter-reviewer Reliability to identify quality of care issues and criteria inconsistencies.
- Maintain requirements of documentation and caseload as reflected in audits to meet compliance with quality standards.
- Conduct case screenings using applicable tools to determine appropriate levels needed to meet member needs.
The case manager will perform the six essential activities of case management.
- Assessment - The case manager will collect in-depth information about a person's situation and functioning to identify individual needs in order to identify members at risk for high cost medical care and develop a comprehensive case management plan that will address those needs.
- Planning - The case manager will determine specific objectives, goals, and actions as identified through the assessment process. The plan should be action oriented and time specific.
- Implementation - The case manager will execute specific intervention that will lead to accomplishing the goals established in the case management plan.
- Coordination - The case manager will organize, integrate, and modify the resources necessary to accomplish the goals established in the case management plan.
- Monitoring - The case manager will gather sufficient information from all relevant sources in order to determine the effectiveness of the case management plan.
- Evaluation - At appropriate and repeated intervals, the case manager will determine the plan's effectiveness in reaching desired outcomes and goals. This process might lead to a modification or change in the case management plan in its entirety or in any of its component parts.
Education:
- Registered Nurse with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law
Experience:
- Minimum of 5 years health care experience with at least three (3) years of clinical experience,
- Prefer two (2) years experience in Utilization Management, Case Management or Managed Care.
Skills/Certifications:
- CCM preferred; required to take examination when eligible.
- Excellent oral and written communication skills, with problem-solving abilities.
- Basic PC computer skills required with emphasis on Microsoft Office applications preferred
Please apply via our career site at:
https://www.bcbst.com/about/careers/openings/
Expires: Feb. 26, 2010
Coding and Compliance Specialist
Minnetonka, Minn.
Responsibilities:
The Coding & Compliance Specialist is Medica's expert resource for implementing and communicating HIPAA approved code sets and guidelines. This position interfaces with providers, as well as Medica medical directors and other internal and external customers, being a key stakeholder in complex claims issue resolution. Provides coding expertise for system set up of new codes as well as ensuring that service codes are appropriately aligned with member benefits in the Certificate of Coverage. Makes recommendations to Medica to generate cost savings and facilitate accurate reimbursement to providers. Develops educational tools to meet the needs of key stakeholders including the Medica Provider College and network providers. Represents Medica at various external State committee meetings working to ensure payer uniformity and national billing standard conformity in order to provide rational and defensible reimbursement policies.
Qualifications:
Bachelor's degree preferred and 3+ years of coding experience related to professional billing and diagnosis coding (CPT, HCPCS, ICD 9 codes) and hospital/facilities bill coding (UB04 Revenue Codes, DRGs, APCs and ICD 9 diagnosis and procedural codes). Coding certification (CPC, CPC-H, CCS, CCS-P, RHIT, RHIA) is required. RN/LPN nursing degree/experience is a plus. HMO and claims experience is helpful.
Please apply online to our careers site at www.medica.com to job #10005.
Billing And Collection Department Manager
Langhorne, Pa.
A wholly-owned subsidiary of a healthcare system with $2+ billion in revenues has an immediate opening for an experienced Home Infusion Therapy Billing and Collection department manager to join our team in Langhorne, PA located between Philadelphia and Trenton, NJ.
JOB SUMMARY: Directs, manages, supervises, implements and maintains efficient operations of the Home Infusion Therapy billing & collections, eligibility and authorization department. Responsible for billing & collections of over $15 million annually, and performing eligibility and authorization for approximately 500 patients monthly. The primary role is to ensure accurate eligibility and authorization process in addition to accurate, timely submission of claims, and collection process.. Oversees the performance and integrity of the department through accurate reporting, monitoring, and training. Directly responsible for developing and implementing methodologies to enhance all eligibility, authorization and billing procedures through system and manual enhancement processes.
MAJOR DUTIES AND RESPONSIBILITIES: (1) Manage the integrity, quality, accuracy, and performance of the department. (2) Develops, implements, and ensures automatic processes are in place to ensure accurate eligibility and authorization and clean claim billing processes. (3) Develops, implements, and monitors all reconciliation processes to ensure claims are billed and received accordingly in the most efficient manner. (4) Develops and implements staff alignment goals across the revenue cycle (RC). (5) Develops, implements, communicates, and monitors reporting tools to identify opportunities for process improvement. (6) Develops and maintains a comprehensive procedure manual of all eligibility, authorization and billing processes. (7) Develops, monitors, and reports on department metric performance to ensure that organizational goals and objectives are completed. (8) Recruits and develops new personnel including, but not limited to, training, development and performance appraisals on current personnel are completed timely along with recommending direction and improvements to help the employee meet department goals. (8) Performs all other duties as appropriate.
SKILLS AND ABILITIES:
Effective organizational skills and analytical abilities required. Must be self-motivated and able to manage, prioritize and complete multiple projects in a timely fashion. Personal computer experience and familiarity with spreadsheet, database and word processing software required.
EDUCATION AND/OR EXPERIENCE:
High School diploma or equivalent required. Master's or Bachelor's level preparedness and related Revenue Cycle certification preferred.
Requires a minimum of 3 years supervisory or management experience in a home infusion therapy and related Revenue Cycle responsibilities. Thorough knowledge of CPT-4 procedure, ICD-9 diagnosis required.
To apply, send resume to resumes@surehealthpharmacy.com Applications accepted until February 15, 2010.
BlueCross and BlueShield of Tennessee
Care Coordinator Supervisor - West Region
Nashville, Tenn.
The Volunteer State Health Plan, Inc. (VSHP) CHOICES program offers person-centered care planning, service coordination, and support services for members receiving long-term care and home and community based services. The care coordinator supervisor is responsible for providing oversight of long-term care and home and community based coordination activities conducted by the care coordination team. The care coordination team promotes interdependent collaboration with the member, physician/primary care manager, and member's family through thorough and objective face-to-face assessment of the member to determine current status and needs; development of individualized care plans; identification and communication of opportunities for care intervention; coordination, authorization, and monitoring of services; proactive education; and routine assessment and monitoring of the member's status, needs, and progress. Many positions will be field based and some will be located at the VSHP office located in Nashville, TN. Travel will be required.
Job Duties & Responsibilities:
- Supervise, direct, and evaluate a diverse group of health care professionals to assure effectiveness of consumer advocate, ancillary, discharge, institutional, care coordinator assistant and home and community-based care coordinator activities, which include, but are not limited to, routinely assessing and monitoring member's status, needs, and progress; developing individualized plans of care for members; managing critical transitions; coordinating appropriate treatments and services; identifying and communicating opportunities for care intervention; authorizing care services; monitoring and ensuring the provision of covered services as a cost-effective alternative; developing and implementing targeted strategies to improve health, functional, and quality of life outcomes; proactively educating members; conducting, reviewing, and revising member's risk assessment and risk agreement; maintaining appropriate and ongoing communications and collaborations with members, their authorized representatives, and providers; and reporting quantifiable impact, quality of care, and quality of life improvements as measured against care coordination goals.
- Under the supervision of the care coordination manager, provide and/or coordinate staff training for maximum performance and provide developmental opportunities.
- Promote teamwork and a positive working environment for the care coordination team.
- Responsible for communicating and mentoring members of the care coordination team to ensure long-term and home and community based care guidelines, policies, and procedures are followed.
- Monitor performance of staff including service performance and adherence to established utilization benchmarks.
- May be required periodically to carry case load of members, when dictated by census fluctuations or staffing coverage.
- Other duties deemed necessary for effective and efficient unit operations.
- Must be willing to participate in Runzheimer Auto Reimbursement program
- 90% day - travel required
- Minimal overnight travel
Education:
- Registered nurse with an active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Act; or Masters in Social Work with an active unrestricted license.
Experience:
- Minimum 2 years of relevant health care experience, preferably in managed and/or long-term care
- 3-5 years of supervisory/management experience required
- 3 years experience providing care coordination to persons receiving long-term care services preferred
Skills/Certifications:
- Excellent communication, leadership, organizational, and problem prevention skills
- Experience with PC based software programs
- Ability to manage multiple projects and priorities
- Valid Driver License
Please apply via our career site at:
https://www.bcbst.com/about/careers/openings/
Expires: February 24, 2010
The Burchfield Group
Sales Coordinator
St. Paul, Minnesota
The Burchfield Group has an immediate opening for a Sales Coordinator responsible for the development and execution of strategic sales activities. This individual will work closely with the Senior Vice President of Business Development and the sales and marketing team on a variety of administrative functions necessary to support the daily operation of the sales and marketing staff. This person will also provide customer support when necessary to help produce and maintain favorable relationships with new and existing customers in order to increase revenue. Qualified candidates MUST have previous sales support experience in a professional environment.
Responsibilities Include:
- Serves as the primary point of contact for managing the Microsoft CRM system data and reporting needs for new sales, renewals and up-selling
- Provides Sales Management Reporting, including administration of Weekly Activity Reports/Executive Summary Preparation and distribution
- Provides Monthly Sales and KPI reports and forecasting
- Assists in the creation and preparation of sales presentations and associated work products
- Coordinates client sales meetings and TBG resources
- Coordinates and prepares for sales/marketing meetings
- Manages travel logistics and planning for sales/marketing staff
- Manages SVP calendar, travel planning, and client files
- Administration of sales/ marketing employment offers, direct report files, and completion of performance reviews
- Back up the Administrative / Operations Assistant during lunch hours and periodically as needed
Skills and Experience:
- Bachelor’s Degree
- 3-5 years of sales support experience
- Understanding of Microsoft CRM system data and reporting
- Strong financial acumen and advanced MS spreadsheet knowledge
- Intermediate MS Powerpoint & Word knowledge
- Excellent organizational skills
- Excellent communication, written, and presentation skills
- Health care or health benefits experience desirable
- Proven ability to work in a progressive, fast-paced environment meeting deadlines with a positive attitude and cool demeanor
- Proven ability to develop and maintain effective, collaborative working relationships
Personal Attributes:
- Excellent listening skills
- Proven ability to work in a progressive, fast-paced environment meeting deadlines with a positive attitude and cool demeanor
- Ability to handle multiple projects and assignments; ability to produce high quality detailed work accurately and on-time
- Proven ability to develop and maintain effective, collaborative working relationships with clients and associates at all times
- Exhibits sound judgment and the ability to make reasonable decisions in the absence of direction
- Strong problem solving and decision-making skills with a high level of focus on customer service
- Doesn’t settle for mediocrity, continue to challenge improvement
- Strive to full understand the business and how to contribute to its success
- Ability to travel
If you are interested in this position, please contact Mary Nutting at mnutting@maintalent.com.
PREFERRED QUALIFICATIONS: 1.Master’s degree in Nursing, MBA, or related business area. 2.Perioperative consulting experience 3.Work experience in multiple surgical environments or institutions.
Contact: Denise E. Hill
HR Administrator
Phone: 314-628-3789
Fax: 314-628-3731
Denise.Hill@Mercy.net
Blue Shield of California
Regional Medical Director – Northern California
(San Francisco, Sacramento, or El Dorado Hills)
Blue Shield of California has been a leading non-profit provider of quality health insurance plans for over 63 years, with a mission to ensure all Californians have access to high quality health care at a reasonable price. Our 4,900 employees serve over 3.2 million Californians.
Blue Shield of California (BSC) is looking for a Regional Medical Director (RMD) who is accountable for the utilization and quality performance of the assigned geographic area for all product lines (HMO, PPO, Medicare, and Healthy Families). To achieve the objectives of the position, the RMD is expected to create a region specific strategy and plan to achieve utilization and quality goals/targets. The scope of the plan will include all providers: IPA/Medical Groups, hospitals and individual providers.
The RMD proactively engages with key delivery system partners to remove barriers to efficient, high quality care for BSC members. These collaborations will include Hospital leadership to address thematic areas of opportunities that could reduce admissions and/or improve timeliness and success of discharges. They will engage IPA/Medical Groups to address areas of outlier performance on key metrics such as hospital bed days and ED usage rates and opportunities. The RMD will engage Individual high volume providers who manage BSC members by providing feedback on issues such as discretionary use of services, quality metrics and performance, and hospital utilization.
The RMD will work with internal BSC partners to meet the objectives of the plan. The RMD works collaboratively to assist in the evolution of medical management best practices by providing clinical input to medical management leadership. The RMD serves as a resource and subject matter expert for numerous BSC functions such as: Medical policy development, COHC projects, Benefit policy and development, Credentialing oversight and Assistance with regulatory audit and oversight.
Must have Active, unencumbered CA license (MD or DO). 10 years managed care experience. Prior health plan experience preferred - specifically as a Regional Medical Director and IPA/Medical Group experience with >200,000 enrollees. Specialty work in Internal Medicine, Family Practice or General Surgery preferred
Interested executives should submit resume to: eric.principe@blueshieldca.com
Blue Cross Blue Shield of Massachusetts
Joint Enterprise (PDP) Product Manager
Boston
Position Summary
The candidate will be responsible for general management and monitoring of a multi-Blue’s plan Joint Enterprise Medicare Prescription Drug Plan. The ideal candidate will have a background in Medicare PDP contracts, Medicare Part D product and project development, and managing day-to-day business issues throughout a product life cycle. The candidate must demonstrate a comprehensive knowledge of the Medicare industry and understand the administrative and PBM operations of a PDP plan. This candidate will be a subject matter expert and key liaison for the Joint Enterprise across internal cross-functional teams and with external PBM’s and vendors. The candidate will lead efforts to meet annual product redesign efforts and oversee cross-functional market readiness activities. In addition, the candidate will identify areas for operational and organizational efficiencies.
Essential functions
· Manages an Interplan business relationship of 4 Blues plans, a PBM, and multiple vendors for a CMS PDP contract.
· Manages cross-functional teams to support program management, including but not limited to weekly Leadership team meetings, Interplan coordination meetings, and vendor oversight meetings.
- Subject matter expert and key liaison for Interplan and vendor business needs; analyzes very complex issues and generates solutions to provide consultative support to assigned areas and to related areas; recommends initiatives to shorten process cycle time, to meet or exceed productivity goals, increase revenue, manage costs, or to enhance programs. The SME identifies business requirements, business issues, defines processes and facilitates issue resolution, and monitors timely resolution of issues.
- Oversight of vendor operations and performance and adherence to contract terms; Develops monitoring tools to assess vendor performance
- Leads cross-functional activities to execute successful CMS bid filings, attestation filings, and annual market readiness.
- Communicates orally and in writing with all stakeholders regularly regarding program or project status and risks.
· Maintains an ongoing knowledge of the PDP industry and its trends; familiar with PDP contract compliance requirements.
· Strong interpersonal skills and ability to communicate throughout all levels of an organization, both orally and in writing.
· Supports ad hoc and special projects as needed.
Challenges and problem-solving
- Utilize the principles of product development, project management, and process improvement to support related business initiatives.
- Build and maintain collaborative relationships and alliances with internal and external business partners to achieve business goals.
- Work requires complex analytical and policy interpretation, independent problem solving and resolution, with infrequent guidance from leadership.
- Uses influencing skills to accomplish program or project goals through people over whom the incumbent has no direct control.
Decision-making authority
- Generally has end-to-end ownership of program or projects.
- May negotiate contracts and develop Requests for Proposals (RFPs).
- Responsible to leader and to matrixed relationships for work performed cross-functionally.
- Create a results-driven environment.
Leadership responsibilities
- Demonstrated ability to translate product and marketing strategies from conceptual objectives to actionable results-driven tasks and outcomes.
- Demonstrated leadership abilities to problem-solve, initiate and drive organizational change.
- Significant experience leading process project management and process re-engineering initiatives.
- Manages relationships with external contacts such as vendors, providers, partners, accounts, community groups, and industry and professional associations.
- Solid written and verbal skills, effective presentation skills, project management, and planning are
essential.
Experience and Education:
- Bachelor's degree and a minimum 5-7 years of product management experience within the insurance or healthcare industry are essential. An MBA is a plus.
Go to www.bluecrossma.com and select Career Opportunities for more information.
Employees Retirement System of Texas
Contract Administrator
Austin, Texas
Essential Functions: Manage designated health and welfare benefit contracts with moderate to considerable risk to the program, from implementation through runoff; develop specialized tools and techniques to accomplish business goals and objectives. Maintain concurrent global and detail focus, while monitoring vendor compliance in fulfilling substantially complex contractual obligations. Document contract deliverables and status in accordance with Contract Monitoring Plan methodology. Establish and track milestones and timelines through completion. Conduct ongoing assessment, and identify, escalate, mitigate or resolve potential or actual operational or contract compliance issues. Lead cross-functional teams to manage day-to-day vendor service delivery, implement modifications, drive initiatives, initiate process improvement, and ensure adequate and timely problem resolution. Manage internal and external stakeholder relationships, facilitate identification of stakeholder requirements, and coordinate business process interfaces between multiple vendors. Maintain detailed archive documenting contract life cycle history. Serve as business communication liaison and focal point for designated contract operations, functioning as a domain expert for assigned contracts and associated vendor operations, and for associated program legislation, rules, policies and procedures. Provide authoritative guidance to internal and external business teams on basic goals and objectives relating to contract activity. Analyze and communicate the impact of legislation, regulations and policy upon related programs. Provide recommendations, and edit portions of complex requests for proposals. Analyze intricate contract requirements, special provisions, terms and conditions for compliance with appropriate laws, regulations, and program, agency, and business unit policies and procedures. Carry forward best practices derived from experience with prior contracts, providing recommendations and guidance for incorporation into subsequent proposals. Review and evaluate vendor larger scale proposal responses, and participate in bidder’s conferences and interviews.
Required Minimum Qualifications: Your application for employment must reflect how you meet each of the following minimum qualifications.
- Graduation from an accredited four-year college or university. Each year of related experience over the required may be substituted for one year (30 semester hours) of required college credit.
- Three years of related experience in insurance, health or benefits administration.
- Track record demonstrating an aptitude for critical thinking, supported by process improvement and problem resolution focus.
- Experience applying independent judgment and creativity to develop, facilitate and/or present solutions and recommended enhancements.
- Excellent analytical, organizational, and written and verbal communication skills.
- Proficiency in Microsoft Word and Excel.
- Experience analyzing, editing, and drafting complex, non-routine documents.
- Experience in leading cross-functional teams consisting of internal and external stakeholders.
- Experience mentoring and training less experienced professionals.
- Submit the ERS Qualifications Form with your State of Texas application.
Preferred Qualifications: Your application for employment should reflect how you meet the following preferred qualifications.
- Prefer in-depth experience in health and welfare contract administration.
- Prefer experience in an account management, business operations, implementation, or start up environment.
- Prefer experience applying business process analysis and mapping, and/or project management methodology.
- Prefer experience writing detailed reports/documents for a professional audience.
- Prefer experience with business systems controls, quality assurance, and auditing principles and methodology.
Other Information: The ERS will conduct a criminal history check on the primary and secondary candidates recommended for the position.
Email: Employment@ers.state.tx.us
Web: www.ers.state.tx.us
Fax: (512) 867-3161
BlueCross and BlueShield of Tennessee
Principal Consultant Finance Technology — 0901144
Chattanooga, Tenn.
Summary:
The purpose of this position is to:
- Proactively support all functional areas using PeopleSoft Financials (GL/AP) in terms of their information, systems and process needs through design, development, implementation, maintenance/support, and management of effective, efficient and innovative technology solutions.
- Partner with and provide leadership to Finance management and staff through active participation/consultation in strategic planning in support of the overall Finance mission as well as the missions of the various other functional areas as needed.
- Liaise with management of non-Finance areas of the company on the correct and appropriate use usage of Finance data and systems in support of their business goals.
Functions:
- Continually and proactively monitor operations in all functional areas of Finance to identify and address information and/or systems needs in support of business goals.
- Design, develop, communicate, document, configure, implement, test, train and maintain technology and process solutions in support of all functional areas of Finance and non-Finance.
- Develop and maintain appropriate relationships with decision-makers in all areas of the organization (not limited to Finance leadership).
- Manage large or multi-disciplinary/multi-phased projects including planning, staffing, and budgeting.
- Develop and deliver functional training to PeopleSoft Financial users as part of the implementation of new or enhanced functionality.
- Maintain current knowledge of industry and Finance trends and tools to provide best practice insight and best-in-class recommendations to management.
- Manage and direct resources in support of all Finance initiatives including third party and hosted applications as well as in-house bolt-on and complimentary applications.
- Manage Finance issues to resolution through consistent, timely and appropriate recognition, tracking and analysis.
- Ensure that all applications and processes used in Finance are appropriately and effectively integrated into a cohesive and sustainable process.
- Ensure that all components as well as their usage are consistent and in compliance with all applicable regulatory, departmental, I/T, and corporate standards, policies and guidelines.
Qualifications:
- Bachelor's degree in Accounting.
- 10 years of professional-level Accounting experience
- Significant PeopleSoft Financials implementation and maintenance experience in all phases of the project life-cycle (including planning, designing, documenting and testing)
- Ability to manage large and/or multi-faceted projects.
- 4 years experience with PeopleSoft Financials version 8.9 or higher including at least 1 full implementation.
- Proficiency with PeopleSoft's Application Designer and Component Interface functionality.
- Experience in analyzing, coding, and tuning SQL.
- Knowledge of, and experience with, creative application of all Microsoft Office products.
- Specific experience with Workflow design/development
- Demonstrated ability to interact effectively with all levels of users and management.
- Proven analysis and problem-solving skills
- Exceptional communications and organizational skills
Please apply via our career site at: https://www.bcbst.com/about/careers/openings/
Expires: 1/6/2010
Senior Executive Level Position – Marketing Unit
East Coast
Our client is a large, growing, very progressive insurance company that is seeking a dynamic, experienced senior executive to augment and expand their marketing department on an enterprise-wide basis. Responsibilities include: marketing/brand strategy development and enhancement; market research; links to PR, crisis communications, product development and advertising; management of a large team of professionals in a matrixed environment; participation in the overall strategic planning and marketing functions for the organization; helping to drive innovation and customer focus; reacting to health care reform initiatives and working as an important part of the senior management team. The best candidates will have an advanced degree in marketing from a top school; many years experience in senior marketing/product development and management roles in large commercial health plans or health insurance companies (outside the industry experience is a plus); a proven track record of end to end marketing services and management of an existing portfolio of marketing services; strong people management and communication skills and a high energy, can-do attitude. Top compensation package, full corporate re-location and an extremely high growth opportunity, offering a seat at the table with the senior management team.
Contact with complete confidentiality: Marc Gouran, President, Solomon-Page Healthcare at mgouran@spges.com
Integrated Solutions Health Network, LLC
President and CEO
Johnson City, Tenn.
Integrated Solutions Health Network, LLC (ISHN), located in Johnson City, Tennessee, seeks applications for the position of President and Chief Executive Officer (CEO). ISHN is an integrated Lease Network Program that supports commercial and government program product lines. ISHN is primarily owned by Mountain States Health Alliance (MSHA), the largest healthcare system in the region with 14 hospitals generating approximately $1.9 Billion in gross revenue.
Integrated Solutions Health Network consists of 1,916 physicians in Northeast Tennessee, Southwest Virginia and Eastern North Carolina made up of 275 provider groups, 531 primary care physicians and 1,385 specialists. ISHN also consists of 14 hospitals, five SNFs, six Orthotic/Prosthetic providers, four DME providers, nine Home Health providers, two Hospice providers, one Laboratory provider, one Rehabilitation facility, and four Ambulatory Surgery centers.
The President and Chief Executive Officer will report directly to MSHA’s executive for Managed Care and Healthcare Networks and to the ISHN, LLC Board of Directors. The President and Chief Executive Officer plans, directs and monitors the activities of ISHN and ensures that the activities of all components of ISHN serve to promote the achievement of its mission, the fulfillment of its vision, and that all business is conducted in accordance with its values. The President and CEO is responsible for day-to-day operations of ISHN and for protecting ISHN’s financial viability by directing and participating in the development of a strategic plan. An important component of the President and Chief Executive Officer’s role will be to prepare and ready ISHN for healthcare reform. Sales and Marketing, Information Systems, Network Development, Utilization Management, and a Medical Director will all report to the President and CEO.
The ideal candidate will have a graduate degree in Healthcare Administration, Business Administration, or another appropriate advanced degree. A minimum of ten years experience in health care including HMO or Managed Care management at a senior level is preferred. A demonstrated track record of building a strong operational infrastructure in an organization and proven success in state-of-the-art contracting, network development, provider relations and network operations is crucial. Exceptional relations skills with physicians, employers and the community at large as well as an excellent reputation in leadership development and staff mentoring are essential components to this role.
Confidential nominations or expressions of personal interest (including a cover letter and resume) may be sent to the ISHN search consultants, Steve Kratz and Shirley Cox Harty, at ISHN_CEO@wittkieffer.com. Items that cannot be sent electronically may be sent to: ISHN_CEO, c/o Witt/Kieffer, 3414 Peachtree Road, Suite 352, Atlanta, GA 30326. Email is preferred.
Regional Account Manager Northeast 0901363
Rockland, Mass.
EMD Serono, Inc. is a leader in US biotechnology, focusing on reproductive health, metabolic endocrinology, and neurology. More than 500 people work in the world-class facilities in Rockland, MA, and approximately 250 work in the field.
Description
In reporting to the Director, Regional and State Accounts (DRAM), the Regional Account Manager (RAM) plays a key role in maintaining overall EMD Serono sales and account management responsibility for the largest regional Managed Care Organizations (MCOs) and national plan affiliates in assigned geographic region. Through executive selling and organizational networking and relationship development, the RAM directs and executes managed care sales and marketing strategy with assigned Health Maintenance Organizations (HMOs), Pharmacy Benefit Managers (PBMs) and State Medicaid and Specialty Pharmacies. Responsible for continual expansion of product sales opportunities, including optimizing product reimbursement and positioning within MCO drug formularies, medical policies and clinical coverage criteria for EMD Serono's entire product portfolio across all Therapeutic Areas (TAs). Facilitates the development of a broad and deep network of relationships within the MCO through strategic and tactical interaction with senior pharmacy, medical, clinical quality and other key decision makers. Develops proposals, negotiates terms and conditions, and implements contractual agreements with accountability for delivering strong financial returns. Leads and manages, via tactical development support of managed care marketing, the strategic execution of physician-level MCO pull-through programs within assigned region aimed at increasing sales and market share within affiliated MC accounts. Leads the Account Team Management Process for assigned regional accounts. Aligns and delivers all necessary resources and expertise towards business objectives and customer needs to advance EMD Serono product sales and market share objectives with the account.
This territory includes: NJ, PA, OH, MD, and DC
Qualifications
EDUCATION/LANGUAGES
- Bachelor's degree required; MBA strongly preferred
- English language required
PROFESSIONAL SKILLS & EXPERIENCE
- 7+ Years BioPharmaceutical/Health Care sales, managed care account and management experience required including:
- 3 Years direct experience in managed care account management
and/or;
- 3 Years direct sales management experience (ABD/RBD) including demonstration of exemplary managed care field leadership and pull-through results
- Executive selling experience
- Experience negotiating large contracts
- Experience in niche market and hyper-competitive environments
- Experience in highly complex sales/distribution/reimbursement channels
- Experience working within a highly matrixed organization
Additional Preferred Experience:
- 2 Years experience in specialty pharmacy marketplace
- 2 Years experience in biotechnology/injectables market
- Managed care marketing, brand management or contracting experience
Please apply online at https://merckgroup.taleo.net/careersection
/2/jobdetail.ftl?lang=en&job=0901363
Confidential Managed Health Insurer
Compliance Auditor
New York City
Position Overview:
Under the direction of the Director, the Compliance Auditor is responsible for working independently on assigned projects. The Compliance Auditor must demonstrate extensive knowledge of Medicaid regulations and monitoring procedures to effectively perform duties independently that support the Compliance Program and HIPAA Privacy activities.
Compliance Auditor must be able to initiate and perform audits and ongoing monitoring or investigations of various health plan operations, such as appeals and grievance, billing, customer services, provider relations and contracting, and other functions relating to proper compliance with governmental regulations and health plan policies.
Ability to develop and implement audit pans, protocols and outcome reports. Ability to interact with all levels of management, as well as federal regulatory agencies. Skilled in data analysis, charting, graphing and flow diagramming necessary. Excellent verbal and written communication skills essential.
Qualifications:
2-4 years of experience in compliance-related matters in the health care industry. Understanding of Medicaid laws and regulations required. Knowledge of fraud and abuse laws helpful. Experience in an auditing environment helpful. BA/BS required.
Send resumes with complete confidentiality to Rachelle Andersen at randersen@spges.com
Confidential Managed Health Insurer
Product Management/Development Leadership Role
New York City
An established, respected managed health insurer in New York City seeks an experienced product specialist to oversee its product portfolio. Responsibilities include managing and refining existing products, developing new ones, setting strategy to expand market share and increase revenue, partnering effectively with relevant internal departments and managing product staff. Strong communication skills essential. BS/BA required, MBA a plus.
This opportunity offers a stimulating business environment, competitive base salary, performance bonus and excellent benefits. Send resumes with complete confidentiality to Rachelle Andersen at randersen@spges.com
Quality Assurance Pharmacist – Bilingual Spanish
Avon Lake, Ohio
SUMMARY:
Quality Assurance I Pharmacist will assist in the processing of prescription orders, assist the call center, and communicate with medical providers to obtain and problem solve prescriptions.
ESSENTIAL FUNCTIONS:
- Pre-check verification of prescription orders – DUR Check
- Receive incoming patient and physician calls
- Place outbound patient and physician calls
- Assist call center staff with inquiries
- Hours – Mon – Fri 9:30 – 6 pm – no nights, weekends, or holidays
QUALIFICATIONS:
- Bilingual Spanish – Speaking and writing
- Must have proficient typing skills
- Must have excellent communication and phone skills
- Must be willing to participate in high volume, fast pace environment with focus on quality and accuracy
- Must have an active, in good standing, Registered Pharmacist License in the state of Ohio
To apply, contact Lisa Calla-Russ at lcallaruss@catalystrx.com.
CatalystRx
Clinical Manager
Reno, Nev.
SUMMARY: Serves as the primary liaison between Catalyst Rx Clinical Operations and Customer Service; provides clinical support to Client Services, Operations, IT and Customer Service Pharmacy Technicians, claims processing system, and plan development as it relates to clinical operations; and functions as a Clinical account manager for assigned client accounts.
ESSENTIAL FUNCTIONS:
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Provides superior clinical consultation and account management with focus on client retention/satisfaction and trend management.
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Conducts utilization and cost analyses, drug utilization reviews and analyses, formulary management, and serves as a drug information resource.
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Participates in client meetings, as needed, and coordinates implementations of clinical projects/programs.
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Provides education for clients, pharmacists, members, and physicians, including one-on-one physician visits and implementation of educational programs.
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Supports Catalyst Rx and client specific Pharmacy and Therapeutics functions and responsibilities.
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Supports elevated customer service and prior authorization inquiries specific to assigned accounts.
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Initiates and develops clinical products and services and supports Sales and Marketing, as needed.
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Provides drug information and clinical support for Customer Service Pharmacy Technicians; provides clinical input and support for claims processing programs; and assists in the development of corporate clinical products and services.
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Supports MTM services and products as needed.
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Supports corporate clinical pharmacy operations as needed.
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Assists and participates in Pharmacy Student/Externship programs.
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Exhibits compliant and ethical behavior in the performance of job responsibilities, including complying with all applicable federal and state laws and regulations, Catalyst Health Solutions Code of Conduct, Business Ethics Policies and Procedures and other policies and procedures applicable to position.
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Actively participates in Catalyst Health Solutions Compliance and Ethics Program, including attending annual compliance and ethics training and reporting suspected violations of the law or Catalyst Health Solutions policies and procedures via Catalyst Health Solutions Procedures for Reporting Incidents of Possible Improper Employment Practices, Misconduct, or Improper Financial/Accounting Practices.
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Follows all policies and procedures related to job.
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Performs other duties as assigned to meet corporate objectives.
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Some travel may be required.
QUALIFICATIONS: Bachelor’s Degree in Pharmacy or doctorate of Pharmacy (PharmD), current state pharmacy license and 2+ years pharmacy practice experience in a managed care environment, including experience developing formularies, presenting at P&T committee meetings, and performing drug utilization analyses; or equivalent combination of education and experience. Strong communication, interpersonal, presentation, customer service, and computer skills required.
To apply, contact Lisa Calla-Russ at lcallaruss@catalystrx.com.
Confidential Clinical Informatics Company
Senior Sales Executives
Boston and Washington, D.C.
Fitzgerald Associates ( www.fitzsearch.com ) has been retained to conduct a search for and recruit two Senior Sales Executives for an early stage next–generation clinical informatics company that provides business intelligence solutions to the health care industry. One position will focus on hospitals and be located in the Boston area; the other will focus on large medical group practices and be located in the DC/VA area. Both positions call for experienced sales professionals who have sold services to providers. Both will be individual contributors and will in time grow their respective sales teams.
Inquiries and referrals are welcome and treated confidentially. Please feel free to share this information with folks in your network.
Contact Geoff Fitzgerald email: gf@fitzsearch.com
Coulter & Associates
Compliance Consultant
Central New Jersey
Coulter & Associates is an actuarial and compliance consulting firm serving the insurance industry for over twenty years. We provide services in accident & health, property & casualty, managed care, and life and annuities. We have an opening for a Compliance Consultant.
We offer a competitive compensation and benefit package, a flexible work schedule, and a business casual work environment. Our office is located in Central New Jersey and is commutable from the suburbs of Philadelphia and New York.
The ideal candidate will have a college degree, 5+ years of relevant work experience, be expert with a variety of insurance products, and be equally comfortable working closely with clients, regulators, consultants, and other members of the insurance community.
Job responsibilities vary from project to project and may include the following:
- Drafting of policy forms and related documents
- Research of applicable state and federal laws
- Correspondence with clients and regulators
- Submitting complete filing packages (including SERFF)
The consulting environment is fast-paced and always changing. Successful consultants are self-motivated, high-energy and can multi-task and maintain momentum on several projects simultaneously.
We are a Microsoft / Adobe environment.
Resume Submission Information
Please submit your resume to: tom@coulter-and-associates.com or fax to 609-443-4103. Recruiters are not welcome.
Salary Range: Not Published
Relocation Reimbursement Policy: Yes
Security Health Plan
Chief Financial Officer
Marshfield, Wis.
Security Health Plan (SHP) is a health maintenance organization owned and operated by Marshfield Clinic in Marshfield, WI. SHP is a physician-directed health plan serving more than 170,000 people in a 32-county area in northern, western and central Wisconsin. The Plan offers a network of 42 affiliated hospitals, more than 3,800 affiliated physicians and other providers, over 55,000 pharmacies nationwide, and offers policies for large and small groups, and individuals and families of all ages and income levels.
The CFO will be a key member of the SHP senior management team, and will be expected to provide strategic leadership regarding future directions and resulting investment decisions. We seek a results-oriented team leader/player with a proven track record of progressive career growth in financial management positions in one or more of the following types of organizations: health plan, health insurance company, large physician clinic, hospital or health system. This executive will be a leader/coach/mentor of others.
Nominations or requests for additional information may be sent to Mike Doody and Janet Guptill through the office of Wendy L. Brower McLeod, Witt/Kieffer, 8000 Maryland Avenue, Suite 410, St. Louis, MO 63105; phone: 314-754-6072 or fax: 314-727-5662. Electronic communication is preferred to SecurityPlanCFO@wittkieffer.com.
All inquiries will be treated with confidentiality.
Confidential Health Plan
Regional Medical Director
San Antonio, Texas
The Medical Director will be responsible for establishing and building strong, lasting relationships with physicians. Will work to positively impact the quality and efficiency of the care all members receive. Serve as the liaison between the health plan and the provider network for all clinical issues.
REQUIREMENTS:
- Graduate of LCME accredited medical school
- Board certified in internal medicine or family practice
- Ability to obtain medical license in Texas
- Minimum of 2 years managed care or payor experience
- Minimum of 3 years clinical experience
- Minimum of 3 years as a physician executive managing physician relationships
- Minimum of 3 years as experience in utilization management
- Prefer someone who is bilingual, but is not mandatory
POSITION RESPONSIBILITIES:
- Manage clinical relationships with physicians
- Develop and execute cost improvement initiatives
- Drive improvement in quality
- Provide coverage for utilization review decisions as necessary
Please send current resume and contact information to resume@grncherryhill.com
Coram Specialty Infusion
Regional Director of Managed Care
Los Angeles
Develops and implements strategies to improve managed care net revenue, payer and business relations, and cash collections for a major specialty infusion market. Core responsibilities include renegotiating and evaluating managed care agreements, interfacing with payers on contract compliance and payment issues, and developing an annual managed care market plan. Responsible for performing on-going monitoring of financial performance of the managed care agreements and the development of strong working relationships with payers and business partners in various markets.
Region Includes; Los Angeles, San Diego, and Arizona. This position is based in Los Angeles and requires approximately 20% travel.
Requirements
Bachelors degree required postgraduate degree or advanced clinical degree preferred.
5+ years in a specialty services sales environment, and prior management experience. A strong understanding of contracting processes. Must exhibit a strong ability and experience working with senior level medical directors and large audience presentations. Payer experienced, specialty pharmacy, sales management, and operations experience required. Experience working with local insurance contracting, driving revenue and gross profit margins, among selling specialty programs.
Because Coram believes in providing a safe work environment, we conduct drug and background checks in our recruiting/hiring processes. AA/EOE, M/F/D/V
Please email resumes to Jeff Battinus at jeff.battinus@coramhc.com, and for additional questions or to speak directly with a Recruiter please call 877-CoramHc
Confidential Managed Care Organization
Medical Director
Baton Rouge, Louisiana
GRN of Cherry Hill has been retained by one of the most competitive and top ranked managed care organizations in the US to fill the position of Medical Director.
POSITION OVERVIEW:
This position reports to the Chief Medical Officer. The Medical Director will be responsible for Quality Management, SAE Medical Management, and Special Projects as well as for providing medical support to the overall departments.
REQUIREMENTS:
- Doctorate Degree in Medicine
- Board-certified and completed an accredited residency program
- Experience in managed care
- Active license to practice medicine in the state of LA (ability to obtain active license in LA is also acceptable)
- Strong background in change management, quality management, and medical management
- Skilled negotiator, adept at conflict management and resolution
POSITION RESPONSIBILITIES:
1. Address quality issues with the Quality Management staff
2. Assist with the assessment and implementation of quality processes
3. Conduct census rounds with the SAE (Service Area Expansion) teams
4. Provide time to meet with the SAE Provider Network providers as needed
5. Perform Utilization or benefit reviews as required
6. Perform Medical Management functions in the SAE areas
Email your resume and contact information to resume@grncherryhill.com if you’d like to be considered for this opportunity.
Confidential Managed Care Organization
Medical Director
Houston
GRN of Cherry Hill has been retained by one of the premier managed care organizations in the southern US to fill the position of Medical Director.
This position reports to the Chief Medical Officer. The Medical Director is responsible for the coordination of medical policy, peer review, quality management, legal/medical issues, and the effectiveness of the Medical Management Program. He/she is also responsible for the administration of medical services including utilization and quality of care issues. Responsible for the development and implementation of clinical criteria based upon previous experience, utilization and reimbursement methods and treatment protocols. Recommend changes and enhancements to managed care plans and services offered.
REQUIREMENTS:
- Must have Doctoral Degree
- Possess current TX license to practice medicine or ability to obtain one
- Prior experience with Medicare Advantage, Part D, and/or Pharmacy is strongly preferred
- Strong understanding of Utilization Management (UM) processes
- Strong analytical skills
POSITION RESPONSIBILITIES:
1. Manage the utilization trends and concerns, participate in daily rounds, weekly case management rounds, and other health services functions designed to manage utilization and identify opportunities for improvement in the utilization program.
2. Provide medical expertise in the evaluation of reimbursement methodology, fee review and claims payment.
3. Provide support and resources to assist the provider network to serve members in an effective manner and foster a climate of cooperation and communication among the leadership of the provider networks.
4. Participate in strategic planning.
Email your resume and contact information to resume@grncherryhill.com to be considered for this opportunity.
Company Confidential
Managed Care Medical Directors
Multiple Locations in the South/Southeast
This position is responsible for the administration of all medical services for the corporation. It is responsible for the coordination of medical policy, peer review, quality management, legal/medical issues, and the effectiveness of the Medical Management Program.
Required Skills
- Oversee the Health Services Department to include Medical Management, Quality Management and Pharmacy Programs.
- Responsible for the administration of medical services including utilization and quality of care issues.
- Responsible for the development and implementation of clinical criteria based upon previous experience, utilization and reimbursement methods and treatment protocols.
- Provide medical expertise in the evaluation of reimbursement methodology, fee review, claims payment.
- Provide support and resources to assist the provider network to serve members in an effective manner and foster a climate of cooperation and communication among the leadership of the provider networks.
- Responsible for recommending changes and enhancements to managed care plans and services offered.
- Participate in corporate strategic planning.
- Assist in provider recruitment and retention.
- Perform annual performance review for direct reports.
- Conducts positive counseling as is necessary and maintains written documentation.
- Reports directly to the Chief Medical Officer relative to the design and implementation of managed care plans for specific patient populations.
- Position may have other physicians reporting directly to them.
Required Experience
Supervisory Responsibilities:
Required Background:
- Medical Degree (MD or DO) from an accredited institution.
- Board Certification through American Board Medical Specialties.
- Unrestricted license in state where operating.
For confidential consideration please email a copy of your CV/resume to Todd Wilson tpw@vermilliongroup.com.
HealthPartners
Medication Therapy Management Pharmacy Program Manager
Bloomington, Minn.
HealthPartners’s continued growth has created an opportunity for a MTM Pharmacy Program manager to work out of the corporate office in Bloomington, Minn. This person is responsible for providing management and supervision of the delivery of clinical pharmacy services to the health plan, HealthPartners Medical Group and Clinics. This person will develop and support pharmacy quality and utilization improvement programs and clinical pharmacy services, and will provide specialized clinical pharmacy services, education, clinical research, and related duties as assigned.
Required Qualifications:
- Bachelor’s degree or Pharm. D from a recognized school of pharmacy
- Licensure in the State of Minnesota as a pharmacist.
- Five (5) years of clinical pharmacy experience preferably in managed care or ambulatory care or successful completion of one or two years specialized post-doctoral residency/fellowship.
- Two (2) years of supervisor/management experience.
Preferred Qualifications:
- Knowledge of managed care pharmacy practice.
- Knowledge of pharmacology, pharmacodynamics and pharmacokinetics.
- Knowledge of pathophysiology and therapeutic disease states commonly found in ambulatory patients.
- Verbal and written communication skills.
- Strong clinical research skills and DUR/DUE experiences
- Computer and software literate.
- Ability to conduct literature searches, to interpret and incorporate into medical proactive.
- Ability to implement changes and develop innovative roles.
- Interpersonal and communication skills necessary to obtain cooperation among Pharmacy, Nursing, and Medical Department.
- Ability to interpret data and generate reports.
- BPS certification preferred.
- Recent clinical practice experience.
Accountabilities:
- Provides supervision and training to clinical staff pharmacists. Directs the delivery of clinical pharmacy services and programs that meet the six aims (effective, efficient, equitable, patient centered, timely and safe) that may include, but are not limited to: prior authorization, lipid management and polypharmacy.
- Develops written policies and procedures for the delivery of clinical pharmacy services.
- Provides specialized clinical pharmacy services including participation on disease management teams, screening of appropriateness of drug therapy, patient education, and active input into the selection of cost-effective pharmaceuticals.
- Participates as a member of health plan and medical group committees or subcommittees (e.g., Pharmacy and therapeutics, Institutional Review Board, etc.).
- Designs, develops and/or supports the development of written appropriate use criteria and threshold standards for review by the Pharmacy Quality and Utilization Improvement Committee or P&T Committee. Conducts or assists in conducting DUR/DUE studies and monitors and coordinates DUR/DUE activities and initiatives.
- Assist in the monitoring of adverse drug reactions and assists in the development of disease management outcome parameters to assess the impact of medications in the treatment of specific disease states.
- Supervises and participates in the education of pharmacy students and postdoctoral residents.
- Provides education to pharmacists, nurses and physicians.
- Participates in applied clinical pharmacy research.
- Prepares and presents new drug reviews and therapeutic class reviews for the HealthPartners P&T Committee.
- Manages and provides academic detailing program activities.
HealthPartners, nationally acclaimed for providing outstanding patient care, offers a comprehensive benefits package. To apply, visit www.healthpartners.jobs and search for job ID 15728.
Employee Health Insurance Management, Inc
Agency Administration Account Manager
Southfield, MI
Job Status: Salary, Full-time
Reports To: Director of Agency Administration
Position Summary:
Under the direct supervision of Director of Agency Administration, assists in the overall administration of the Agency business in insurance brokerage
Primary Duties:
1. Review client annual renewals and prospective clients for solid insurance options by bidding or quoting out to various health insurance carriers.
2. Preparation of renewal presentation binder including recommended plan designs and spreadsheet set-up.
3. Client meetings including presentation of renewals, open enrollment meetings or as requested.
4. Preparation and submission of benefit changes to insurance carriers.
5. Prepare, assemble and distribute enrollment literature and contracts.
6. Responsible for annual carrier audits and maintaining files.
7. Customer service support including general client inquiries, service calls and problem resolution.
8. Direct communication on a daily basis with insurance companies, clients and internal staff.
9. Maintain up to date documentation of communications and activities between EHIM and client and/or agent through CRM system.
10. Initiating client “check-ins”, status calls, and “tickler” service as directed by immediate supervisor.
11. Proactively keeps themselves and the department educated on industry trends and developments to accurately communicate to clients.
12. Duties as assigned.
Position Requirements:
• Minimum 2 years college in general business or similar field
• Minimum of 4 years experience working in health insurance industry with customer service experience
• Must have experience and industry knowledge of various medical carriers and their respective products including but not limited to BCBS of MI, BCN, and Priority Health
• Must possess excellent written and verbal communication skills
• Must be extremely organized with a strong attention to detail, exceptional customer service and follow through skills
• Demonstrate solid time management abilities and capable to work under general direction on multiple tasks with demanding timelines
• Possess strong analytical skills and out of the box thinking/creativity
• Must possess strong computer skills including proficient use of Excel, Word, and Outlook
• Must be flexible, dependable
The Burchfield Group
Senior Claims Auditor
St. Paul, Minn.
Company
The Burchfield Group is a privately-held consulting firm, which specializes exclusively in the pharmacy benefit management (PBM) arena. The company's goal is to provide industry-leading insight that guides plan sponsors through the complexities of the pharmacy benefit market. From prescription benefit management proposal analysis and audits to on-going utilization review, Burchfield's comprehensive approach combines advice, advocacy and action, along with meticulous attention to detail and follow through.
Position Overview
The Burchfield Group has an immediate opening for a Senior Claims Auditor to join its growing Audit Services department. The auditor would be involved in conducting pharmacy benefit audits on behalf of both employer and managed care organization accounts. Our consulting group conducts both traditional commercial Pharmacy Benefit Manager (PBM) audits as well as providing comprehensive Medicare Part D audit and compliance services for Part D prescription drug plans. Our audits focus on a variety of areas, including prescription claim pricing, pharmacy benefit plan set-up and administration, fraud, waste, abuse and other targeted areas as defined by our clients and the marketplace. In this position, the auditor/analyst would be expected to run the technical audit as well as develop and present individual audit results to our clients.
Skills and Experience
- Strong Excel and Access skills to facilitate independent and high quality analyses of pharmacy claims data
- Excellent written and verbal presentation skills
- Pharmacy benefit experience, ideally with past or current history working for a Pharmacy Benefit Manager (PBM) or pharmacy group of a managed care organization
- Understanding of pharmacy benefit financial terms and terminology
- Ability to read and interpret pharmacy benefits contracts is preferable
- Medicare Part D knowledge a plus
- Audit experience preferable
- Negotiation skills, particularly in relation to managing recoveries when contractual and/or administrative issues are identified
Duties Include
- Client conversations to coordinate the collection of information to successfully conduct audit projects
- Establish audit parameters in our audit system and conduct audit runs
- Define and conduct ad hoc analyses to validate or disqualify audit outliers
- Written and oral presentations to clients regarding the audit findings
- Collaborate and negotiate with pharmacy benefit vendor audit departments to seek final audit resolution and obtain client recoveries, when applicable
To apply: Contact Mary Nutting at mnutting@maintalent.com
EMD Serono
National Account Manager
Central/Western U.S.
EMD Serono, Inc. is a leader in US biotechnology, focusing on reproductive health, metabolic endocrinology, and neurology. More than 500 people work in the world-class facilities in Rockland, Mass., and approximately 250 work in the field.
Description
In reporting to the Vice President of Sales, the National Account Manager (NAM) plays a key U.S. commercial role in maintaining overall EMD Serono sales and account management responsibility for the largest, widest-reaching Managed Care Organizations (MCOs) and Specialty Pharmacies (SPPs) in the country. Through executive selling and organizational networking and relationship development, directs and executes managed care sales and marketing strategy with assigned Health Plans, Pharmacy Benefit Managers (PBMs) and Specialty Pharmacies (SPPs). Responsible for continual expansion of product sales opportunities, including optimizing product reimbursement and positioning within MCO and MpD drug formularies, medical policies and clinical coverage criteria for EMD Serono's entire product portfolio across all Therapeutic Areas
PROFESSIONAL SKILLS & EXPERIENCE
Minimum Required:
- Bachelor's degree required; MBA strongly preferred
- 8-10+ Years BioPharmaceutical/Health Care sales and managed care account management (or similar) or commercial management experience including:
- 3-4+ Years direct experience in managed care account management (National or Regional Accounts) with demonstration of outstanding results
- Executive and business-to-business selling experience
- Experience negotiating large contracts with demonstration of successful results
- Experience in highly complex sales/distribution/reimbursement channels
- Experience working within a highly matrixed organization
Additional Experience Preferred:
- 2+ Years experience in biotechnology/injectables market
- Specialty pharmacy channel experience
- Medicare Carrier, CMS or Federal Markets business acumen and experience
- Oncology or HIV market expertise
This is a field based position, candidates may live anywhere in the US, preferred locations are the central/west regions of the US.
Please apply online at https://merckgroup.taleo.net/careersection/
2/jobdetail.ftl?lang=en&job=0900922
Employee Health Insurance Management
Agency Administration Account Manager
Southfield, Mich.
Under the direct supervision of Director of Agency Administration, assists in the overall administration of the Agency business in insurance brokerage
Primary Duties
- Review client annual renewals and prospective clients for solid insurance options by bidding or quoting out to various health insurance carriers.
- Preparation of renewal presentation binder including recommended plan designs and spreadsheet set-up.
- Client meetings including presentation of renewals, open enrollment meetings or as requested.
- Preparation and submission of benefit changes to insurance carriers.
- Prepare, assemble and distribute enrollment literature and contracts.
- Responsible for annual carrier audits and maintaining files.
- Customer service support including general client inquiries, service calls and problem resolution.
- Direct communication on a daily basis with insurance companies, clients and internal staff.
- Maintain up to date documentation of communications and activities between EHIM and client and/or agent through CRM system.
- Initiating client “check-ins”, status calls, and “tickler” service as directed by immediate supervisor.
- Proactively keeps themselves and the department educated on industry trends and developments to accurately communicate to clients.
- Duties as assigned.
Position Requirements
- Minimum 2 years college in general business or similar field
- Minimum of 4 years experience working in health insurance industry with customer service experience
- Must have experience and industry knowledge of various medical carriers and their respective products including but not limited to BCBS of MI, BCN, and Priority Health
- Must possess excellent written and verbal communication skills
- Must be extremely organized with a strong attention to detail, exceptional customer service and follow through skills
- Demonstrate solid time management abilities and capable to work under general direction on multiple tasks with demanding timelines
- Possess strong analytical skills and out of the box thinking/creativity
- Must possess strong computer skills including proficient use of Excel, Word, and Outlook
- Must be flexible, dependable, reliable and willing to work variable hours
- Must be a team player
Health Plus
Contracts Specialist
Brooklyn, N.Y.
Job Summary: Under the overall direction of the Associate Director –Contracting, the Contract Specialist:
- Provides expertise to the development of Hospital and Ancillary contracts
- Negotiates with Providers and is responsible for tracking the status of contracts during the negotiation process
- Develops analytical summaries of upcoming contracts
- Has Project Management duties of contracting initiatives
Principal Duties and Responsibilities:
- Assists Associate Director in effectively negotiating contracts
- Prepares financial analysis and makes recommendations of reimbursement proposals for new and existing contracts based on data analysis
- Prepares analysis/interpretation and makes recommendations on language requests when negotiating or renegotiating contracts
- Upon finalization of negotiations, prepares final contracts for provider signature, draft amendments to contracts and conducts follow-up and tracking as needed
- Coordinates the implementation process of new contracts with the Provider Relations, ITS and Claims departments
- Investigates and resolves provider contracting inquiries and complaints
- Investigates and resolves intra and interdepartmental contracting inquiries
- Maintains financial grid of hospital rates and business terms that are not the standard for Health Plus (includes tracking trend increases)
- Coordinates quarterly meeting with each area of Provider Relations
- Monitors Ancillary network growth and recruitment needs
- Other activities and duties as assigned by the Associate Director
Job Specifications:
- Working knowledge of managed care concepts and health care delivery
- Knowledge of facility and/or ancillary contracts, specifically managed care contracting language and reimbursement methodologies e.g. DRGs, APGs, APCs
- Must be detail-oriented
- Must have excellent interpersonal skills and be able to work with people at all levels within and outside the organization
- Must have strong analytical and writing skills
- Must know word processing, must have good spreadsheet application skills. Experience with rate modeling, database management programs and/or MedStat
Required Education and Experience:
• B.A. or B.S. degree, Masters degree preferred, health related field preferable
• Five years experience in health care delivery or managed care with at least two years contracts experience
Contact: Kellyn M. Cuthbert at Humanresources@healthplus.org.
Health Plus
Internal Compliance Auditor I (2)
Brooklyn, N.Y.
Job Summary:
The Internal Auditor I will assist the Compliance Department in all functions as needed, with primary responsibility for retroactive review and analysis of enrollment applications for compliance with regulatory and contractual standards.
Principal Duties and Responsibilities: *Essential Functions
- Schedule, plan and conduct internal assessments, reviews, and audits.
- Conduct an ongoing review of enrollment submissions by individual representatives in a prescribed format.
- Conduct retrospective reviews of enrollment applications and related documents as part of FE Integrity retrospective review requirement.
- Verify policies and procedures are being interpreted and applied properly and carried out as intended by management.
- Where changes in operating conditions have made policies and procedures obsolete or inadequate; recommend corrective action.
- Review and evaluate the adequacy of accounting, financial, reporting and other operating controls.
- Prepare written reports identifying results at the conclusion of each audit assignment.
- Interact with Health Plus staff as needed.
- Perform other projects assigned by the supervisor.
Job Specification:
Must have good product knowledge of State Department of Health regulations pertaining to eligibility and documentation requirements for Medicaid, Child Health Plus, and Family Health Plus; knowledge of CMS requirements for Medicare Applications is required, but is not a prerequisite for the job.
Ability to works cooperatively with departmental staff in meeting overall goals, developing strategies, plans and materials.
Must establish and maintain good working relationship with the Marketing, Enrollment, Retention, and Member Services Department.
Must have good organizational skills and ability to handle multiple tasks simultaneously.
Must be able to communicate effectively.
Must be self motivated.
Must be accurate and able to focus on detail
Knowledge of Health Plus desk top applications.
Required Education and Experience:
An Associate’s degree from an accredited college or in lieu of the degree; the incumbent must have two (2) to three (3) years of enrollment experience in a Managed care HMO setting.
At least 1-2 years of progressive Managed Care Enrollment experience required.
Contact: Kellyn M. Cuthbert at Humanresources@healthplus.org.
Health Plus
Sr. Auditor, Compliance Audit Unit
Brooklyn, N.Y.
Purpose of Position:
Responsible for providing oversight of Corporate Audit Workplan and related compliance activities. Test controls to ensure conformance with State and Federal regulatory requirements, Health Plus standards, applicable statements of policy and procedures, sound principles of internal control, and in a manner consistent with both company and high standards of administrative practice. Essential duties to include, but are not limited to:
Key Responsibilities:
- Participating with the Director in evaluating the adequacy and effectiveness of internal controls for compliance with regulatory requirements.
- Review documentation and test internal controls of various departments, with emphasis identified regulatory and compliance risk areas.
- Plans and conducts independent appraisals of the effectiveness of Health Plus procedures and standards.
- Establish internal policies and procedures for Audit Unit.
- Interacting with appropriate members of management during the course of the audit and in reporting conclusions.
- Prepares and submits reports on the results of testing, identifying control deficiencies, developing remediation plans, issuing recommendation to operational areas and conducts fraud investigation follow-up audits, including enrollment, and marketing.
- Performing follow up audits to ensure that operational areas comply with implemented plans of corrections resulting from external audit findings.
- Oversees an ongoing monitoring of marketing/ enrollment reviews and targeted audits related to investigations of compliance issues
- Informing the Director in a timely manner of any potential problems in situations that may require direction or input.
- Makes recommendations on the systems and procedures under review; provides on-going follow-up reporting to monitor management response and implementation.
- Conducts an annual corporate-wide risk assessment.
- Oversees staff of 3
- Performs other duties as assigned.
Education and Experience:
The ideal candidate will have corporate operations, financial and/or compliance audit experience with some technology audit knowledge.
Financial Accounting understanding considered a plus; College degree is required;
Certification including one or more of: CIA, CFE(Certified Fraud Examiner) or AHFI (Accredited Health Care Fraud Examiner), are a plus but not required
Qualifications/Skills:
1. Baccalaureate Degree with a concentration in finance/accounting and audit.
2. Minimum two years paid employment as an internal auditor.
3. Two years experience in internal audit in a health care insurance/HMO setting.
4. Thorough knowledge of audit procedures, including planning, data gathering techniques, test and sampling methods.
5. Ability to analyze and evaluate findings and to prepare and present concise and clear written reports.
6. Strong Project management skills.
7. Excellent written and oral communication skills.
8. Proficiency in Microsoft applications (Word, Excel, Power Point, Access).
Contact: Kellyn M. Cuthbert at Humanresources@healthplus.org.
Qualis Health
Director, Business Development
Seattle
Every day, across the country, Qualis Health works with our partners to improve healthcare delivery and health outcomes for millions of Americans. As one of the nation’s leading healthcare quality improvement organizations (QIOs), we’re dedicated to ensuring that patients receive the right care, at the right time, in the right setting. To learn more, visit http://www.qualishealth.org/
Reporting to our Vice President of Business Development, you’ll pursue and secure new business opportunities in health information technology (HIT), medical home model, patient safety, care transitions, and related quality improvement initiatives by:
- Positioning, differentiating, developing, and promoting Qualis Health’s broad array of consulting services.
- Identifying and cultivating relationships with potential customers and other key decision makers.
- Exploring and developing strategic alliances with potential product and service partners.
- Contributing to the capture planning, business pursuit, and proposal lifecycle.
You bring a combination of at least five years of experience in all of the following:
- Program and/or project development, preferably in HIT, medical home model, patient safety, Care Transitions, or related healthcare quality improvement initiatives; and
- Business development, including proposal and/or grant writing.
Advanced knowledge of healthcare and specifically government healthcare benefit programs (e.g., Medicare and Medicaid) plus a Bachelor’s degree in a health-related field are required. A Master's degree and/or current, active, and unrestricted healthcare licensure are preferred.
At a time in America’s healthcare when there are major problems to solve, we invite you to join us by emailing your resume to jobs@qualishealth.org using “Director, Business Development” as your subject line.
Qualis Health is an Equal Opportunity Employer M/F/D/V and has been named one of “Washington’s 100 Best Companies to Work For 2009” in the July edition of Seattle Business Magazine.
AvMed Health Plan
Chief Information Officer
Miami, Fla.
The Vice President & Chief Information Officer (VP/CIO) will provide the overall responsibility and accountability for leading the Information Services/Technology strategies for SantaFe HealthCare and its Affiliates, with specific focus and accountability for AvMed Health Plan. The VP/CIO will report to the President & COO of AvMed Health Plan with a dotted line strategic relationship to the President & CEO of SantaFe HealthCare. The VP/CIO will also serve as a key advisor to the other members of the senior management team in developing and executing strategic and operating plans to maximize the use of Information Services/Technology in support of business objectives for AvMed and for providing strategic technology leadership and oversight for SFHC and its Affiliates.
A bachelor’s degree in Information Systems, Computer Science or other quantitative undergraduate disciplines is required. A master’s degree in Business or Healthcare Administration is preferred. AvMed seeks a seasoned executive with a solid track record managing complex IT environments, preferably in a progressive managed care organization. The VP/CIO will be a strategic leader, aligning IT with the mission and values of the organization and establishing a high quality, transparent and customer service oriented IT organization. A focus on the mission of the organization and the community it serves is essential.
Contact Linda Hodges, IT Practice Leader of Witt/Kieffer at 630-575-6157 or lhodges@wittkieffer.com.
Partners Healthcare System, Inc.
Financial Analyst — McLean Hospital
Belmont, Mass.
The Opportunity
This is a wonderful opportunity to join a vibrant, small fiscal program at a Partners HealthCare System specialty hospital and have an opportunity to become involved in many facets of hospital fiscal management. Partners HealthCare System (PHS) was founded in 1994 by Brigham and Women's Hospital and Massachusetts General Hospital and is a major teaching partner of Harvard Medical School. PHS is an integrated health care system that offers patients a continuum of coordinated high-quality care. Focused on patient care, teaching, and research, this large system includes primary care and specialty physicians, community hospitals, the two founding academic medical centers, specialty facilities, community health centers, and other health-related entities. McLean Hospital, the site of this position, is the specialty psychiatric hospital within this network.
The Position
Reporting to the hospital CFO, the Financial Analyst works closely with hospital management, local finance staff, and all departments in Partners central finance, including Accounting, Patient Accounting, and Budget departments (capital and operating), to monitor and analyze volume trends, track historical statistical trends, and coordinate preparation of annual volume budget. S/he prepares monthly statistical and financial reports using various systems and databases, and also provides analyses of operating budget, operating performance, special projects and strategic initiatives for assigned areas.
Qualifications
The successful candidate will be self-motivated, resourceful and able to take initiative; have take-charge ability; possess strong oral and written communication skills; have a solid understanding of financial statements; demonstrate excellent analytical, conceptual and critical thinking talent; and have strong competency in Excel, Access, Word and PowerPoint. Bachelor’s degree in a relevant field is required.
To apply, forward resume and cover letter to cmoconnell@partners.org
PHS is an equal opportunity employer with a demonstrated commitment to hiring individuals who reflect the diversity of the communities it serves.
KHR
Manager of Utilization Management
Riverside County, Calif.
Are you a visionary with an entrepreneurial spirit and drive? If so, connect with us. If you thrive in a fast-paced environment, this is an opportunity to join a dynamic organization where your vision, innovation, skill and intelligence are efficiently used, consistently appreciated, genuinely valued, and richly rewarded.
In this highly important role incumbent will assume leadership position in directing and managing UM department, the development and implementation of utilization management and case management services, processes, and policies. The individual must have a strong goal orientation with a strong commitment to quality and ethical behavior. The ability to work within a ‘team’ approach is essential. Major responsibilities:
- Responsible for working directly with the IPA’s/medical groups and hospital to ensure coordinated, continuous cost effective quality health care for members. Responsible for the development of a comprehensive resource directory of Health and Human Services locally. Responsible for serving as primary liaison to IPA’s/medical groups and hospitals for case management support. Responsible for developing policies and procedures regarding admission reviews, concurrent reviews, referral processes for members that are eligible for carve out programs. Responsible for oversight of Case Managers serving as primary contact between company and external agencies, such as CCS, Medi-Cal Field office for fee-for-service transactions and other related programs. Responsible for developing and implementing a catastrophic case program to ensure appropriate management, tracking and continuity of care for members with catastrophic illnesses. Responsible for the design and development of utilization management and case management reports. Develop, implement, and evaluate program policies and procedures. Successfully works with managers from other departments and units on issues that impact other organizational entities. Any other duties as required ensuring company operations are successful.
- Ensure the privacy and security of PHI (Protected Health Information) as outlined in company's policies and procedures relating to HIPAA compliance.
Minimum Qualifications:
Possession of a valid Registered Nurse license issued by the State of California. Possession of a valid State of California driver’s license.
Experience:
Five or more years of utilization management/case management in a health care delivery setting. Experience in an HMO or experience in managed care setting strongly preferred.
This opportunity offers very competitive compensation, great work environment, work-life balance, as well as excellent benefits package and other perks.
For immediate and confidential consideration please forward your resume to Krystian Florek, BSN at floreka@kellyservices.com
Executive Director, Client Services
Nationwide
SUMMARY:
Oversees and directs the regional operations of the Client Services account management staff to ensure account management efforts result in a greater than 95% client retention rate; implements best practices throughout all regional locations. Oversees key new client relationships with the focus on client satisfaction, retention and increased profitability for Catalyst Rx.
ESSENTIAL FUNCTIONS:
- Manages, trains, and directs assigned staff members to ensure adherence to Best Practices guidelines. Assists with identifying and developing new Best Practices procedures, as necessary.
- Participates as a preceptor/mentor and role model for client services team members for client presentations, implementation activities and day to day client interaction. Manages and mentors Directors, Senior Account Managers, Representatives and Coordinators. Provides feedback at least quarterly on the level of accomplishment of personal and departmental goals. Provides feedback at least quarterly on the level of accomplishment of personal and departmental goals. Develops strategies to optimize performance of regional staff.
- Works closely to fulfill departmental responsibilities and improve company-wide processes, with a focus on corporate profitability.
- Serves in a leadership role for Client Services projects including, status brief development, staff training and orientation, performance guarantee metrics, and BDS/Web enhancements.
- Provides leadership and corporate-wide initiatives including, but not limited to:
- New and Add-on client implementations
- Corporate Acquisition/Integration activities
- Implementation of New Products/Services
- Process/Productivity Improvement Initiatives
- Participates in internal and external sales preparation meetings, RFP initiatives, and finalist sales presentations as necessary.
- Establishes multiple corporate relationships and participates in client sponsored events/ charities to cultivate in-group growth through these relationships.
- Follows all policies and procedures relating to job responsibilities and participates in the development and maintenance of departmental policies and procedures for Client Services, as appropriate.
- Exhibits compliant and ethical behavior in the performance of job responsibilities, including complying with all applicable federal and state laws and regulations, Catalyst Health Solutions Code of Conduct, Business Ethics Policies and Procedures, and other policies and procedures applicable to position.
- Actively participates in Catalyst Health Solutions’ Compliance and Ethics Program, including attending annual compliance and ethics training and reporting suspected violations of the law or Catalyst Health Solutions polices and procedures via Catalyst Health Solutions Procedures for Reporting Incidents of Possible Improper Employment Practices, Misconduct, or Improper Financial/Accounting Practices.
- Significant travel required.
- Performs other duties as assigned to meet corporate objectives.
QUALIFICATIONS:
Bachelor’s Degree and 5+ year’s health care, health insurance, managed care, PBM, or related industry experience (equivalent combination of education and experience considered.) Must have knowledge and experience in leading account management teams. Proven track record of success in new client implementations and negotiations. Strong organizational, interpersonal, communication, analytical, and presentation skills required. Must be flexible, resourceful, adapt quickly to change, and work effectively in a fast-paced, team-oriented, and high-growth environment.
Send your resume to Lisa Calla-Russ at lcallaruss@catalystrx.com
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