Health Business
Job Openings

CVS/Caremark, Senior Legal Counsel, (5/9)
Horizon Blue Cross/Blue Shield of New Jersey,
Manager, IT-CDH (5/8)
Community First Health Plans, Supervisor, Health Services Resolution (5/6)
American Health Holding, Inc., Director, Disease/Wellness Management (5/5)
Blue Shield of California, Compliance Program Auditor (5/5)
BlueShield of Tennessee, Chief Reinsurance Analyst (5/1)
Confidential — Healthcare Services Organization, Director of Reinsurance (5/1)
Puget Sound Health Partner, Chief Operating Officer (4/29)
Community First Health Plans, Contract Manager — Health Plan (4/29)
Humana Inc., Innovation Consultant (4/29)
Confidential — Integrated Healthcare Services Organization, Regional Sales Representative (4/28)
Blue Cross Blue Shield Florida, Care Management Medical Director (4/24)
Confidential Health Insurance Company
Chief Information Officer (4/21)
Albert Einstein Medical Center, RN - Quality Improvement Manager - Heart and Vascular Institute (4/21)
Confidential Managed Care Organization, Nurse Care Manager/Medical Coder (4/17)
Confidential Health Plan, VP-Pharmacy Services Position (4/14)
Blue Cross Blue Shield of Florida, Senior Director, Hospital Network Contracting (4/8)
Confidential Medicare HMO, Chief Financial Officer (4/4)
Highmark Inc., Clinical Quality Program Analyst II (4/4)
Aetna, Inc., Medical Director (4/2)
WellPoint, Inc., Business Change Director (4/1)
ZeOmega, Director level position (3/25)
Confidential - Technology Organization, Executive Vice President of Sales and Marketing (3/24)
Managed Care Organization, Chief Operating Officer (3/18)
BeneSys, President (3/17)
Harvard Pilgrim Health Care, Contracting Specialist (3/14)
Blue Cross Blue Shield of Tennessee, Vice President, Medicare Advantage and Medicare Supplemental Products (3/6)
Brigham and Women's Hospital, Director, Billing Compliance (2/20)
CalOptima, Chief Financial Officer, (2/19)
Shands Healthcare, Vice President, Managed Care and Network Development (2/13)
Brigham and Women's Hospital, Compliance Auditor (2/12)
APS Healthcare, Health Intelligence Director, Public Program Support (2/1)

Providing legal advice and support to inquiries and requests; reviewing applicable statutes and regulations, drafting and/or reviewing contracts, licensure and other materials; and monitoring ongoing programs and operations for legal compliance.

Monitoring product development activities to evaluate compliance with law; working with business partners to structure programs to address legal issues while meeting business objectives.

Working collaboratively with business partners to address legal issues while meeting business objectives.

Serving as a subject matter expert to the Law Department, Government Relations, Compliance and other business units.

QUALIFICATIONS:
A graduate of a top tier law school with excellent academic credentials, commitment to high standards in a work product and strong business acumen. Excellent written and oral communication skills, initiative, drive and self-confidence are required. Ability to collaborate effectively and work as a team player.

EDUCATION:
Juris Doctorate Required; prefer top tier law school

EXPERIENCE:
5 to 7 (for Legal Counsel) or 8 to 10 (for Senior Legal Counsel) years experience in healthcare regulatory work involving prescription benefit management services, health care services or pharmaceuticals preferred combination of private practice and inhouse experience preferred

APPLY VIA OUR CAREER CENTER AT:
https://sjobs.brassring.com/EN/ASP/
TG/cim_home.asp?partnerid=9379&siteid=37
Search openings by the above listed Req #.

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The position is accountable for managing the delivery of Information Technologies support services for one or more insurance payor claim systems and CDH experience is required. Responsible for system technical activities in requirements gathering, testing, production support and system configuration to provide day to day assistance to internal users and for the implementation of functionality and processes that improve the performance of the system in meeting the enterprises needs. This position may also manage and monitor projects and support teams to ensure the availability of resources throughout the development and implementation of new systems. Additionally this position oversees administrative and system expenses including budget preparation, defining priorities, ongoing monitoring of expenses against the budget and authorization of payments related to system services.

Education/Experience:

• Requires a Bachelor's degree from an accredited college or university, preferably in Business Administration or Computer Science. Prefers a Masters degree.
  
• Requires a minimum of 5 years experience managing I/S projects & experience implementing major projects.
  
• Requires a broad experience (5 to 7 years) in the health insurance industry, preferably with a Blue Cross Blue Shield plan.
  
• Requires a minimum of 3 years supervisory experience.

Please send a resume to susan_dyl@horizonblue.com

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Community First Health Plans, a locally-owned and operated, not-for-profit HMO, was established in 1995, by University Health System, specifically to begin providing health care coverage to the citizens of Bexar and the surrounding seven counties. Our commitment to our members is to provide exceptional health care benefits backed by outstanding service, delivered by people who live right here in South Texas.
In our ten years of existence, we have made great strides in becoming a fully mature health plan with a strong balance between our commercial and government-sponsored programs. Our 110,000+ members are divided almost equally among Commercial, Medicaid and Children's Health Insurance Program (CHIP).

Position Summary
As the Supervisor of Health Services Resolution, the selected candidate will ensure that all member/provider oral or written UM complaints and appeals are acknowledged, investigated and resolved according to CFHP policies, as well as those of the National Committee on Quality Assurance (NCQA) and federal & state regulatory entities. It will be the supervisor's responsibility to enhance Community First's reputation for prompt, fair handling of complaints and appeals. Supervises the activities performed by Community First staff regarding the UM complaint process and all aspects of the UM appeals process, including documentation, coordination with Community First departments, and organization of the Complaint Appeals Panel and other required elements of the process. Additionally, he/she will continuously ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) related policies in regards to all aspects of operations within Health Services.

Qualifications Required
Graduation from an accredited school of professional nursing is required, BSN preferred. A current license to practice professional nursing or to practice vocational nursing issued by the Texas Board of Nurse Examiners is required. Minimum of two years experience in managed care and/or the insurance industry is required, preferably in a management capacity. Five to ten years of progressively responsible experience along with an associate's degree in nursing or a licensed vocational nurse may be substituted in place of a bachelor's degree. A minimum of one year experience in managed care complaints and appeals resolution or quality improvement/management is preferred. Must demonstrate a complete or thorough knowledge of medical review criteria used to make utilization review decisions

How to apply:
Please complete an online application at www.UniversityHealthSystem.com/hr for immediate consideration. You may also submit your CV to 210.358.4765 or rosa.ramirez@uhs-sa.com. University Health System is an equal opportunity/affirmative action employer.

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American Health Holding, Inc. (AHH), a Worthington-based national medical management firm is seeking an experienced Disease/Wellness Management professional to oversee the disease and wellness management program.

To oversee and direct management of delivery, forecast and resource management, plan, assign and direct work and process improvement through a culture of metrics management. Assures quality delivery of service will establish and monitor workflow and employee performance as well as set direction of delivery of service.

• Coach, mentor, and direct work of health coaches, registered nurses, clinical support staff, and others as appropriate
• Accountable for the URAC, HIPAA standards and state/federal regulations.
• Ensure implementation of process improvement activities at site towards universal standards
• Communicate vision, direction and change as appropriate building on culture of health and value.
• Work with the Quality oversight team to identify and impact process and outcomes in the all products
• Act as a liaison with product management/training to enhance, improve and implement enhanced solutions
• Act as a liaison with Sales to assure excellent customer service and site visit support
• Act as a liaison with Account Management to assure excellent customer service
• Regularly and openly communicate with all members of the management team and direct reports

Candidates must have a 4 year college degree with a minimum of five years experience in DM including 2-3 years management experience in a health care business setting. The preferred candidate will have the required education and experience, including an active nursing license and a solid record of accomplishments of success in managing change, and excellent communication skills.

Qualified candidate please submit your resume to:

American Health Holding, Inc.,
Attn: HR – DDWM100
West Old Wilson Bridge Rd.P.O. Box 6016
Worthington, OH 43085-6016
or
humanresources@ahhinc.com
or
Fax: 614.839.3240

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Blue Shield of California is the state's third-largest health plan. Founded in 1939, and headquartered in San Francisco, Blue Shield of CA has 3.3 million members, 4,300 employees and more than 20 offices throughout California.

Responsibilities:
Position reports to the Manager, Education and Audit.
Demonstrates understanding of CMS requirements related to MAPD and PDP operations and compliance; has extensive familiarity with relevant resources and is available to provide technical assistance and guidance to operating units within BSC.

Working independently, conducts audits of all departments involved in the delivery or administration of BSC’s Medicare Advantage and Medicare Part D plans for compliance with CMS and BSC standards.

Assists Compliance Manager in developing compliance audit instruments and protocols. Revises policies and procedures to comply with regulatory changes.

Prepares analyses/reports based on audit results, including recommendations for corrective action.

For detailed job description & to apply, please click here.

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Description
Manage the day-to-day operations of the department. In addition to maintaining a case workload including analyzing stop loss quotes from multiple vendors on group prospects and renewals, ensuring claims are paid accurately & timely, policies are issued timely and accurately, and brokers are paid accurately and timely on a monthly basis. This position is also responsible for reviewing the risk and working with vendors in determining the appropriate price to ensure BCBST self-funded customers receive a fair and equitable quote. This position is also responsible for ensuring the daily activities of stop loss administration are handled efficiently and accurately by the department. Responsible for ensuring the training and mentoring needs of staff are identified and addressed.

Functions
Manage staff of 5 to 6 professional/exempt level positions.

Analyze multiple stop loss vendor rating methodologies to ensure premium rates and aggregate factors for new business and renewals are appropriate to meet growth and profitability goals.

Liaison/Facilitate with outside consultants, brokers, stops loss vendors and BCBST field representatives to ensure prospects and renewals meet the customer's needs while maintaining profitability goals.

Executive management reporting and analysis.

Maintain expertise with the stop loss underwriting field and utilizing this to update and develop methodologies used within the department.

Oversee the database for both renewals and prospective accounts, which monitors persistency, closing ratios, and profitability.

Act as liaison between ReOps and IT/IS on system/report related needs and issues.

Qualifications

• 10 years group underwriting experience or 8 years of stop loss underwriting experience
• Strong coaching/mentoring and training experience
• Strong negotiating skills
• Excellent Analytical Skills
• Actuarial background preferred
• Ability to effectively communicate with and make presentations to accounts, brokers, & BCBST staff
  Prefer a minimum of 2 years supervisory experience

Apply Online at our Career Center
https://www.bcbst.com/about/careers/openings/

Recruiter Contact Information:
Kimberly Nash
Talent Acquisition
Direct :423.535.3787
Cell: 423.463.6706
Fax : 423.535.5792
BlueCross BlueShield of TN
801 Pine Street 1-M
Chattanooga, TN 37402
Kimberly_Nash@bcbst.com

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This innovative approach stems from existing limitations that currently exist on the part of carriers and TPAs that have failed to respond to an employer needs regarding employees poor health, absenteeism, and poor productivity. This organization is providing a solution to that market demand through a full and comprehensive array of products and services designed to lower employer costs. As an ESO, this organization will be able to function pro-actively to curb healthcare costs beyond the mere network discounting and payment of claims. This innovative model is not just a distinguishing factor, but will be a clear and compelling competitive advantage that insurance carriers and TPAs will have difficulty competing with.

Currently, this organization processes over 2.4 million claims annually, has revenues exceeding $20M, and has strong brand recognition. It is an industry leader as evidenced by the following:

• All customer service calls are answered in less than 30 seconds
  
• 95% of all claims are paid in 10 days or less
  
• Financial payment accuracy of 99.4%
  
• Client retention of 94%
  
• Positive new business growth

As for the position, the selected candidate will: design and manage the quote process for new business and renewals including staffing responsibilities and workflow. Establish and maintain relationships with "preferred" carriers including stop-loss, life, disability, etc. Implement and monitor bonus agreements with carriers. Create and maintain standards of performance for carriers. Monitor and resolve issues including contractual and claim related problems. Oversee departmental training. Provide ongoing support to sales and account management staff.

The qualified candidate must have several years of experience and a strong understanding of medical stop loss, self-funded and fully-insured benefits administration, claims adjudication and underwriting; including rate setting, risk assessment, and plan design adjustments.

Contact: Brian Howard
The Howard Group, Inc.
bhoward@thehowardgroup.com

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• Be the local industry leader in supporting health care delivery
  
• Promote our members' health through local provider innovation
  
• Be responsible stewards of health care resources
  
• Be an active partner in improving the health of our communities
  

General Summary of Duties: Responsible for all core operations functions including claims, member services, enrollment, and information technology and policies & procedures via direct and outsourced partnerships. This position requires a strong knowledge of managed care, Medicare and the many aspects involved in effective enterprise-wide management.

Primary Responsibilities

1. Define, implement and maintain a systems and service strategy for the operations function to support the vision, mission, and objectives of Company’s strategic plan.

2. Provide strategic leadership and accountability for development and management of the service model, service initiatives, and technology deployments aimed at improving service, quality, and efficiency.

3. Oversee the daily activities of the operations function including claims, member services, enrollment/disenrollment, and information technology and procedure analyst.

4. Develop and maintain monitoring and management controls to ensure compliance with Company, local, state, and federal requirements.

5. Serve as operations thought leader to promote positive relations with partners, vendors, and distributors.

6. Timely, complete, and accurate management and monitoring all health plan transactional information.

7. Develop and direct the implementation of strategic business and/or operational plans, projects, programs, and systems.

8. Establish and implement short- and long-range departmental goals, objectives, policies, and operating procedures.

9. Key member of the Executive Management Group and participate in Board and Board Committee and other planning and policy-making meetings as designate.

10. Represent the company externally to media, government agencies, funding agencies, and the general public.

11. Recruit, train, supervise, and evaluate department staff.

Required Knowledge, Skills, Abilities

1. Strong knowledge of health plan management systems, Medicare Advantage, prepaid health care delivery systems (including IPA operating principles),

2. Strong technical skills and experience in health plan and managed care operations, including benefit design and support, claims processing, systems administration, and provider contracting and reimbursement methodologies and training.

3. Ability to manage contracting, negotiating and management of vendors/partners

4. Ability to establish and maintain cooperative working relationships with individuals at all levels of the organization

5. Ability to analyze problems, interpret complex data, research and formulate plans, solutions and course of actions

6. Communicates effectively via written and verbal communication.

7. Strong interpersonal relations and team building skills, with demonstrated experience in leading change in complex organizational settings.

8. Ability to participate in and facilitate teams to produce quality materials within tight timeframes and simultaneously manage several projects

9. Strong project management and systems thinking.

10. Experience in strategic and enterprise-wide systems planning and execution.

Education and Training:

1. Bachelor degree in health and administration, business administration, or the equivalent.

2. Master degree preferred

3. Minimum 10 years increasing responsibility in health plan and/or managed health care organization settings; three or more years in a senior-level management position

For further information or to refer potential candidates please contact:

Larry Loo, MPH
CEO
Larry.L@OurPSHP.com

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Community First Health Plans, a locally-owned and operated, not-for-profit HMO, was established in 1995, by the University Health System, specifically to begin providing health care coverage to the citizens of Bexar and the surrounding seven counties. Our commitment to our members is to provide exceptional health care benefits backed by outstanding service delivered by people who live right here in South Texas.

This is the perfect opportunity for someone that is in a lead position, looking for advancement in their career.

Position Summary:
The Contract Manager will supervise, assist and direct the activities of the Provider Relations Representatives and respond to the issues escalated by the Provider Relations Representatives. Provides solutions to problems in accordance with plan's policies and procedures. Plans and implements methods to improve work procedures and areas that need improvement. This position is also responsible for managed care contracting, as directed, for the purpose of increasing revenue. The Contract Manager will assist in developing and maintaining relationship with health providers through the contract negotiation and renegotiation process.

Requirements:
Bachelor's Degree in Health Care Management or related field is required. A minimum of three years experience in managed health care delivery, or managed care contracting or operations environment is required.

For further consideration please apply online at www.universityhealthsystem.com/hr
Or to learn more about Community First Health Plans please visit www.cfhp.com
Please contact Rosie Ramirez, Human Resources (210) 358-2281.

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Humana Inc., headquartered in Louisville, Kentucky, is one of the nation's largest publicly traded health benefits companies. Humana offers a diversified portfolio of health insurance products and related services - through traditional and consumer-choice plans - to employer groups, government-sponsored plans, and individuals.

Today, Humana is a leader in consumer engagement. Throughout its diversified customer portfolio, the company provides guidance that can both help lower costs and lead to a better health plan experience.

Are you a fit?
Are you interested in helping people meet their health goals? We are. The Innovation Center within Humana creates products, service and experiences which allow us to support consumer health by understanding our consumers, building relationships and engaging and retaining consumers.

We need individuals who are creative and can utilize that creativity to drive insights, learning & actions through innovation. If you are that person, please read on.

Assignment Summary
The Innovation Consultant has experience developing new products, programs or services and developing and leading process management efforts in a complex environment. This role is responsible for management of and compliance with the Innovation Center’s quality management system which is designed to streamline the development of new products and services for consumers. The primary focus of this position will be managing and enhancing multiple incentive and reward initiatives across multiple business segments. This is accomplished using the following skills: understanding of the new product development process, having strong analytical skills with the ability to turn data into a succinct and effective message, understanding of loyalty and rewards programs, understanding of the health benefits industry, and having a passion for consumer engagement.

Responsibilities include but are not limited to:

• Serves as a new product development innovator
  
• Researches and develops concepts for new innovative products across the breadth of Humana’s businesses
  
• Develops business plans for new business initiatives
  
• Develops prototypes for new products
  
• Works with sales, marketing, IT and operations areas to fully understand how the design of a new product would impact each constituent group
  
• Maintains project plans, issue logs, documents, etc. for assigned projects
  
• Facilitates meetings, follows up on outstanding issues, and resolve cross-project discrepancies
  
• Gives presentations/demos on newly developed projects and concepts
  
• Assists Project Analysts and Managers in the analysis of data as required
  
• Assists other Innovation Center team members in related projects as needed

Competencies for the role include:

• Ability to understand and explain complex processes
  
• Ability to understand internal Humana systems
  
• Excellent organizational skills
  
• Can manage multiple, time sensitive tasks with the appropriate level of sensitivity
  
• Effectively interacts with associates at all levels of the organization
  
• Functions at a high level with minimal supervision
  
• Excellent communication skills, both oral and written
  
• Adept at writing concept briefs and business plans
  
• Highly self-directed
  
  To apply for this role email: DJarvis1@humana.com

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This organization has been in business for over 40 years and has created a comprehensive suite of services that include:
Claims Management (of): Health, dental, retiree, COBRA, Health Savings Accounts, to name a few.
Integrated Healthcare Delivery: disease management, case management, multiple network access, non-network fee negotiation, utilization review, PBM, nurse line and so on. The organization also offers employer-sponsored, on-site healthcare clinics (4 are in current operation).

As for the positions, the selected candidates will be responsible for sales of this company's full product and services portfolio. Target market is 200 lives and above selling through the broker/consultant community through out the general Midwest. Average case size for this organization is currently over 1000. Territories can be easily expanded based on existing relationships of the candidates.

This organization is looking for experienced large case sales professionals. The qualified candidates will have previous large group sales experience in the self-funded market. Further, the qualified candidate should have.

• A superior ability to manage the sales process
  
• A positive track record of sales or sales activity in the self-funded arena
  
• Previous and on-going relationships with major consulting and brokerage houses
  
• A comprehensive understanding of all health and integrated healthcare products.

Contact: Brian Howard
The Howard Group, Inc.
bhoward@thehowardgroup.com

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Witt/Kieffer is pleased to be assisting Blue Cross Blue Shield of Florida (BCBSF) in their search for a Care Management Medical Director. BCBSF, a leader in Florida’s health industry, is headquartered in Jacksonville, Florida. Along with its subsidiaries, BCBSF serves more than 8.6 million people and employs more than 8,000 individuals.

The Care Management Medical Director will be a key member of the management team, and BCBSF seeks a creative, team-oriented and passionate professional who is interested in revamping products and services of the organization, building new products, and continuing to make BCBSF uniquely different in the marketplace. This opportunity is NOT your typical utilization management/care management position.

Because of BCBSF’s commitment to hiring the best and most talented individuals, they are open to experienced physician leaders who are currently in primary practice or executive physicians who have not yet had the role of medical director but are ready for that next step. BCBSF wants an individual who has had a clear track record of success in their field and someone who is comfortable with change. The successful candidate must have a high degree of motivation, drive and energy, be proactive and must be someone who wants to be part of the changing behavior and culture at BCBSF. The individual must have a MD or DO degree from an accredited Medical school and a license to practice medicine in the state of Florida without restriction, or the ability to obtain a license.

Confidential nominations or expressions of personal interest may be sent via email to: BCBSF_CareMgmt@wittkieffer.com or to the BCBSF search consultants: Stephen J. Kratz and Shirley Cox Harty, c/o Witt/Kieffer, 3414 Peachtree Road, Suite 352, Atlanta, GA, 30326. Phone: 404/233.1370; Fax: 404/261.1371; Email communication is preferred.

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The Chief Information Officer will provide leadership in systems development, telecommunications, applied technology, technical services, data center operations, office services & strategic companywide & business-unit decisions involving information technology. The position will be responsible for creating a seamless information technology function with operations spread out over multiple locations. This includes the assessment & application of existing & new technologies to improve efficiency & effectiveness, development & vetting of preferred technology vendors, contract negotiations & performance monitoring.

The ideal candidate will have:

• a minimum of 5-8 years of progressively responsible management level experience in health care INSURANCE services
  
• a bachelor's degree in computer science or related field, with a master's degree in information systems or MBA preferred
  
• a proven management track record of ensuring information & telecommunications systems & technology achieve the service, financial & operational goals of an organization
  
• the ability to develop & maintain information technology departments in multiple locations as well as create new departments form the ground up in a rapid growth environment
  
• an entrepreneurial personality
  
• TriZetto Facets background

The position is located in Northeast, Pa. The salary range is from $150-$170k.

Respond to:

Bob Courtright
Courtright & Associates, Inc.
rjcx@comcast.net

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Albert Einstein Medical Center, with more than 700 beds, is a teaching hospital offering a full range of advanced health services to patients of all ages in the Philadelphia Community. Our specialties include routine to highly specialized medical and surgical treatment. Some factors that contribute to our top rankings are specialized intensive care units, state-of-the-art inpatient and outpatient operating suites, a Level-1 trauma center, the latest diagnostic technology, and a high level of commitment from our dedicated and experienced staff of physicians and nurses.

In this role, you will assume immediate responsibility for:

• Assisting in the implementation, coordination, assessment, evaluation and development of Albert Einstein Healthcare Network's Quality Management and Performance Improvement Program for the Heart Institute
  

If you possess the following experience, please apply immediately:

• Bachelor of Science in Nursing preferred
• Minimum of one to two years Cardiac Nursing experience required
• Minimum of one to two years experience in Quality Management/Performance Improvement required.
• Strong knowledge of medical terminology required
• Strong computer skills including knowledge of Microsoft Office required
• Ability to perform basic analysis of information is required
• Strong organizational skills required
• Ability to work independently required
• Licensed as a professional Nurse in Pennsylvania

Albert Einstein Healthcare Network offers its employees unparalleled career opportunities including competitive compensation, attractive benefits plan including medical/dental/vision coverage with health insurance coverage effective the first of the month after hire. We also offer generous vacation time, tuition reimbursement and low-cost employee parking. EOE.

Please apply online using the following link to the Albert Einstein Healthcare Network website:

https://v2.projectix.com/einstein/jobboard/
JobDetails.aspx?__ID=*A017F034683F68BC

To learn more about all AEHN job opportunities please visit our website at www.einstein.edu , go to career opportunities, and browse all jobs!

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The Nurse Care Manager/Medical Coder – Post-Service Review performs advanced and complicated case review and first level determination approvals for inpatient, outpatient and ancillary service requests, medical necessity appeals or claim review requests including high dollar claims after the delivery of services. Case reviews include determination of
medical appropriateness and medical necessity requiring considerable clinical judgment, independent analysis, critical-thinking skills and detailed knowledge of departmental procedures, clinical guidelines and
coding conventions. Acts as a liaison between medical management network management, claims, member services and other departments to resolve retrospective review issues.

ESSENTIAL DUTIES AND RESPONSIBILITIES:
Conducts advanced and complicated clinical review for inpatient, outpatient and ancillary service requests, medical necessity appeals or claims review requests including high dollar claims after the delivery of services. Case reviews include determination of medical appropriateness and medical necessity using considerable clinical judgment, independent analysis, critical-thinking skills and detailed
knowledge of medical policies, clinical guidelines, benefit plans, product configuration and coding rules/convention. Makes first level approval determinations when appropriate. Conducts retrospective review of service requests, medical necessity appeals or claims submitted by contracted and non-contracted providers, delegated and non-delegated providers for all product lines.

Reviews, triages, prioritize and complete cases to meet required turnaround times including claims service standards. Performs research and analyzes complex issues, including member needs at the time services were delivered. Acquires and applies appropriate clinical records, clinical guidelines, policies, EOC, Benefit Policy and coding guidelines.

Using professional judgment, independent analysis and
critical-thinking skills applies clinical guidelines, policies,
benefit plans, etc to complete case review and determinations. Conducts rate negotiation, when necessary as per policy, with non-network providers, utilizing appropriate reimbursement methodologies.

Summarizes cases including analysis of medical records and appropriate application of all applicable policies, guidelines and benefit plans.

Develops determination recommendations and presents cases to Medical Director for potential denial determinations or when Medical Director input is needed.

Identifies potential TPL/COB cases, investigate TPL/COB issues and notifies the appropriate internal departments.
Develops and/or reviews appropriate documentation and correspondence reflecting determination. Assures accuracy, completeness and conformance to standards.

Recognizes potential quality care concerns and refers as appropriate. Identifies and refers members who may benefit from disease management or case management and makes appropriate referrals when those referrals were not previously made.

REQUIREMENTS:
Certification/License:
Valid state LVN or RN license.
Current Certification as a Certified Coder or Registered Health Information Technician (CPC, CCA, CCS, or RHIT).

Experience:
Minimum two years of clinical acute care experience.
One year of managed care experience preferred, including with an emphasis on claims review, medical coding/billing or utilization/case management.

Experience using standardized clinical guidelines/criteria and with medical coding required.

Able to operate PC-based software programs including proficiency in Word, Excel, PowerPoint, Access and Project.

In return for your expertise, we offer a professional and team atmosphere, great work environment, excellent pay, great benefits package, 401K, weekly pay, and other kudos.

If you are available and interested in this position, please contact us toll-free at 866-660-1488 or forward your current resume in a Word or PDF format attachment via email to floreka@kellyservices.com.

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Solomon-Page's client is a rapidly growing, health plan company that is seeking a VP of Pharmacy Services to lead its pharmacy management segment. The ideal candidate will be a Pharm D. with a minimum of ten years experience in managed care pharmacy services with a health plan, health insurance carrier, PBM, DM or Care Management company. Experience with formulary development and management, PBM and vendor management, substantial staff, rebates and strategic planning required. High growth potential, top compensation and stock option program.

For further information or to refer potential candidates please contact in confidence: Marc Gouran, Solomon-Page Group at mgouran@spges.com

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Blue Cross Blue Shield of Florida (BCBSF) in Jacksonville, Florida invites nominations and applications for qualified individuals for the position of Senior Director, Hospital Network Contracting (SD HNC). Witt/Kieffer, an executive search firm serving healthcare, higher education, and the not-for-profit communities has been retained by Blue Cross Blue Shield of Florida to conduct this search.

BCBSF seeks a highly experienced, creative, team-oriented and passionate senior professional as its new Senior Director. Reporting to the Vice President, Network Management, the SD HNC is the company’s lead strategist and negotiator for provider contracts. This position is responsible for maintaining and advancing the company’s relationships with hospital CFO’s, CEO’s and CMO’s regarding payment, reimbursement and pay-for-performance strategies.

A Bachelor’s degree or equivalent work experience is required; a Master’s degree in Business or Health Administration is preferred. The ideal candidate will have a minimum of eight to ten years experience in the health care industry with a minimum of eight to ten years experience successfully negotiating hospital contracts.

Nominations, referrals, and expressions of interest (including cover letter and resume) should be sent confidentially to BCBSF_Contracting@wittkieffer.com. Items which cannot be submitted electronically may be sent to Shirley Cox Harty c/o Witt/Kieffer, 3414 Peachtree Road, Suite 352, Atlanta, GA, 30326 or faxed to 404-261-1371. Inquiries may be directed by phone to 404-233-1370.

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Lee Calhoon & Co., a healthcare executive search firm founded in 1970, has been retained by a Medicare HMO to recruit and evaluate candidates for the position of Chief Financial Officer.

SCOPE OF POSITION: This position has been acknowledged as being one of the most important hires our Client will make which is critical for the ongoing growth and profitability in the evolving Medicare healthcare niche. Our Client is pursuing an aggressive business plan, one that will reinforce their status as one of the regions leading providers of Medicare services, while continuing to develop innovative solutions to the rising cost of healthcare, and a vehicle that will bring new products to its members that allow personal accountability for health, and offer superior services that improve care, health, and wellness.

RESPONSIBILITIES:

• Responsible for protecting and securing the financial assets of the company.
• Will develop and maintain financial plans, programs and policies that are consistent with general acceptable accounting practices of the company.
• Directs financial activities (i.e. Accounts Payable, Accounts Receivable, and Payroll), and cash management including financial planning and reporting, general accounting, group purchasing, reinsurance, Medicare and Provider Contract Administration, fixed assets, audit, preparation of budget, tax and treasury functions, actuarial, underwriting, billing, and claims.
• Accountable for internal financial controls and lending relationships, audit liaison, corporate profit planning, capital expenditure, working capital requirements, financial direction in acquisitions and divestitures and overall financial management.

EXPERIENCE:

• Brings a minimum of 5 to 10 years of responsible senior management accounting experience who has ideally worked for a $250-500MM public Payer/HMO company.
• Is an individual who has aggressively managed growth with a health plan.
• Has the ability to understand and identify financial needs of our Client and has the availability to secure capital as needed.
• Develop a positive communication with financial markets and the investment community to position and convey our Client's uniqueness and growth.
• Has the ability to create a cost management information real-time system.
• Be a corporate financial strategist with M&A experience.
• B.A., Accounting or related field, Masters and/or M.B.A. desired.
• C.P.A. certificate desired.
• MUST HAVE health plan experience, M&A knowledge/successes.

COMPENSATION:

A very generous compensation package, which includes a base salary and bonus with an equity position in the company, has been created that will provide us the opportunity to attract and reward the best talent available. Simply put, we will recruit the best of breed talent and will do what is warranted to compensate these professionals for their results oriented experience.

We welcome sharing detailed information about this engagement with you personally. For additional information contact: Lee Calhoon at leecalhoon@aol.com.

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Highmark Inc, a nonprofit health plan corporation, is Pennsylvania's largest health insurer based on membership. Providing over seven decades of superior service and access to quality health care, Highmark embraces workforce diversity as a means to best serve its increasingly diverse customer base. By tapping into the different skills, abilities, and perspectives of a diverse workforce, Highmark is able to serve and anticipate the needs of a changing and expanding marketplace. Highmark is currently seeking candidates for the following position to be based in Pittsburgh.

CLINICAL QUALITY PROGRAM ANALYST II: This position is responsible for the ongoing administration of duties related to large-scale, highly visible projects typically supporting strategic provider contracting initiatives, primarily supporting Highmark's hospital pay-for-performance program. Consistency and accuracy are crucial elements of this position. Incumbent will be a member of the Provider Contracts Support (PCS) project development and communication team. This is a mid-level, professional position in a series of classifications responsible for the resolution of a broad range of administrative and business operations issues, and serving as an analyst associated with activities relating to facility provider contracting. The incumbent will assume accountability for following through to completion various tasks in support of strategic business initiatives. Position is also responsible for problem resolution within PCS, and collaboration with multi-disciplinary management teams in advancing corporate initiatives. Candidate is expected to operate with autonomy and independence, and execute regularly scheduled and routine tasks without prompting from management. The incumbent is responsible for coordinating various corporate resources as a means of achieving results. Incumbent will report to the Manager, Provider Contracts Support.

REQUIRED QUALIFICATIONS: Bachelors degree in Business or Clinical discipline OR 4 years work experience in business or a clinical field within a hospital or managed care environment. Three to five years of experience in a Managed Care or Hospital setting. Two years work experience utilizing PC software applications with a preference for reporting tools/languages.
OTHER QUALIFICATIONS: Familiarity with quality concepts and measurement. The ability to manage multiple tasks simultaneously and reprioritize tasks appropriately. Knowledge of HBCBS/KHPW contracted provider types and HBCBS/KHPW products and programs. Ability to create documents of professional format and content. Proficiency with project management software as well as project reporting and HPLC standards. MBA, MPH or other master's level clinical degree preferred. Strong written and oral communication skills and is able to think on his/her feet while dealing practically with sometimes conflicting demands and expectations.

To submit your resume for consideration, go to our website: www.highmark.com and click on the Careers link under the About Highmark section of the site. Follow the instructions there to view our current open positions. To apply for this position, use reference #052785. Highmark Inc., an equal employment opportunity employer, strives to capitalize on the strengths of individual differences and the advantages of an inclusive workplace.

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The Medical Director (MD) is responsible for providing clinical expertise and business direction in support of medical management programs to promote the delivery of high quality, constituent responsive and cost effective medical care. The MD is a critical medical and business leader and contact for external providers, plan sponsors, and regulatory agencies and participates in strategic medical management.

The National Accounts (NA) Patient Management (PM) Medical Director will report to the Head of National Accounts Medical Management. This person will provide medical director support our new Dedicated Patient Management unit in Albany, NY as well as backup coverage for San Antonio, TX, Blue Bell, PA & Richfield, OH. Specific responsibilities include:

• Maintains positive relations with customers serviced by the dedicated PM sites.
  
• Performs chart reviews and makes medical necessity decisions for the unit.
  
• Participates in customer presentations, as needed, to support NA sales and marketing efforts.
  
• Adheres to Aetna Policies & Procedures for timeliness/criteria for decision making.
  
• Cross cover for other NA PM Medical directors.
  
• Maintain collaborative relationships with other medical directors in Aetna.
  
• Leverage Aetinfo and PM databases and organization to develop value-added information for assigned customers.
  
• Use of data analysis to identify opportunities for quality improvement and to positively influence practice patterns.
• Collaborates with Site lead on unit initiatives.

The ideal candidate

• Possesses sound clinical knowledge
  
• Possesses general knowledge of the health benefits business, clinical issues, trends and medical management
  
• Has ability to anticipate the customers needs/concerns/reactions may be and proactively presents opportunities and options
  
• Demonstrates a bias for action consistent with strategy
  
• Can operate successfully in a highly matrixed and changing environment
  
• Lives in or willing to relocate

We value leadership, creativity and initiative. If you share those values and a commitment to excellence and innovation, consider a career with our company.

Please note that benefit eligibility may vary by position. Click here to review the benefits associated with this position. Apply to this job

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The Business Change Director is responsible for the development, implementation and monitoring of regional planning and project activities. May specialize in one area of organization effectiveness (planning, project portfolio, or culture/change) or be assigned to directly support an area of the business unit and ensure activities are aligned with regional strategy. Essential duties may include, but are not limited to: aligns and implements the planning methodology and practices that support the regional planning process; provides project management/portfolio oversight across the business unit; identifies and address changes to the operating model to align the organization to the business plan; provides process, project, and change management methodology coaching/consulting support to both local and regional initiatives; leads the project prioritization and scheduling activities for the region; provides expertise to the business areas in culture/change management activities; provides expertise in process planning activities; provides expertise in portfolio management activities; supports the execution of the operating plan for the region; and performs other duties as assigned.

• Experience working with cross-functional workstreams and inter-dependent processes highly desirable. Knowledge of care management programs and/or operations desirable.
  

Qualifications

BA/BS and seven years managing mid to large-scale change/project initiatives or an equivalent combination of education and experience. Masters degree preferred. Expert knowledge of planning models and methodology, project management and change management experience (strategic and execution) required. Strong leadership, relationship management and negotiation skills required. Strong analytical and problem solving skills required.

To apply for this position, click here.

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ZeOmega is a company with a 7 year track record of delivering innovative care management software solutions to leading disease management (DM) vendors and health plans.

This is a great opportunity for anybody looking to be part of the excitement of a growing company with excellent career development prospects.

The individual will be responsible for:

• Presenting ZeOmega software solutions and demonstrate capabilities of our products
  
• Help with training users on our software products
  
• Assist with business proposals and contracts
  
• Establishing and maintaining long-term client relationships
  
• Assisting in marketing efforts

The ideal candidate will have at least 3 years experience in Managed Care (Payer side) . A strong plus would be experience in one or more of the following areas in Group Health Utilization Management / Review, Case Management, Disease Management
Requisite Skills:

• Nursing or case manager background is strongly preferred but not required.
  
• Excellent communication skills
  
• Strong persuasion skills
  
• Confident, self driven and ambitious, with a good track record.
  
• Team player with leadership potential

Will report to VP of sales

Travel:
The position will involve between 10% - 30% travel, and all travel will be within the US.

Compensation:
The compensation package is attractive and commensurate with experience. Compensation will be a combination of salary and commission with health care benefits. We keep our people happy !

Please respond with resume to dallasjobs@zeomega.com

Web site: www.zeomega.com

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This is an Executive Vice President of Sales and Marketing position with a growing benefits technology organization located in the Midwest. This organization helps Healthcare Payers and Administrators improve the performance of their benefits management processes with breakthrough real-time technology solutions. This real-time, web based solutions is the healthcare industry's only real-time end-to-end payer solution for administering benefits across all product lines of business, market segments, and funding sources. This organization was founded by executives with over 60 years of combined healthcare IT and real-time claims processing experience. Based on market research and reasonable growth projections, this company anticipates four-fold growth from its present revenues over the course of the next four years. The company's 60 business and technology professionals support more than 20 health and dental benefit payers, administrators, and managed care clients. The organization is searching for an EVP of Sales and Marketing to strategically lead the organization through this rapid growth period.

For this position, the selected candidate will craft and implement a sales and marketing plan that will include branding, public relations, media relations, print and web-based marketing among others. The executive will also need to build, and then manage a national sales force (likely no more than 4 producers, 2 already in place) with all of those attending responsibilities.

The qualified candidate must be a seasoned sales and marketing executive with combined experience from both benefits technology and group health insurance.

Contact: Brian Howard
The Howard Group, Inc.
bhoward@thehowardgroup.com

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The chief operating officer (COO) provides leadership, administrative and management support, strategic planning and overall direction of the health plan.

Manages health care system departments efficiently and effectively to maximize quality of services and profits of the plan. Implement corporate policies regarding organization structure and responsibilities as well as product development, introduction and implementation to assist the company in achieving market leadership status.

CONTACT: ES&P SEARCH
Executive Search & Placement
Sonia Varian
(818)707-7118
espsonia@pacbell.net

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The ideal candidate must have a bachelor’s degree; a MBA is preferred. General management (P/L) experience in a TPA would be a plus. A proven track record of success in implementing systems for continuous cost improvement and application of technology to drive gains in customer service and productivity is helpful.

Confidential nominations or expressions of personal interest may be sent to email: BeneSys_Pres@wittkieffer.com or to BeneSys search consultants: Stephen J. Kratz/Shirley Cox Harty, c/o Witt/Kieffer, 3414 Peachtree Road, Suite 352, Atlanta, GA, 30326. Phone: 404/233.1370; Fax: 404/261.1371; E-mail communication is preferred.

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The Contracting Specialist reports to the Director in Network Contracting, and is responsible for developing and negotiating contractual and financial arrangements. He/she plays a key role in establishing, managing and promoting positive relationships with HPHC's providers. The Contracting Specialist is responsible for contract ownership, and has an indepth familiarity with key provision and details of arrangement including volume, methodology, operational conditions, margins, membership and budget specifications. He/she must demonstrate market knowledge.

Requirements:

• BA/BS Degree or equivalent, Master Degree Preferred
  
• Minimum 7 years of health care related experience and at least 3 years of direct contract negotiation experience.
• Must demonstrate comprehensive understanding of complex financial arrangements and quality programs across health care products. Require strong knowledge of healthcare market.
  
• Requires exceptional financial, analytical and problem solving skills, and understanding of legal documents.
  
• Requires excellent communications skills, written, verbal and presentation.
  
• Ability to work independently and must be self directed, must also be able to work in team environment to reach goals and objectives.

We believe in a healthy balance of work and personal life. We do our best to support our employees in making the most of their lives both inside and outside of work. We have an excellent benefit package and are "T" accessible.

Harvard Pilgrim is an equal opportunity employer and does not discriminate in employment on the basis of race, religion, gender, gender identity, age, sexual orientation, national origin, or veteran or disability status. Harvard Pilgrim complies with all applicable laws concerning hiring and employment practices.

Please submit your resume directly to: www.harvardpilgrim.org Careers page.

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Witt/Kieffer has been exclusively retained by Blue Cross Blue Shield of Tennessee (BCBST) to assist in the recruitment of a Vice President, Medicare Advantage and Medicare Supplemental Products. BCBST, an independent, not-for-profit, locally governed health plan company, has been centered on the health and well being of Tennesseans for more than 60 years. Founded in 1945, BCBST serves nearly 3 million members and has more than 4,400 employees.

The Vice President, Medicare Advantage will be located in Chattanooga, TN and report to the Senior Vice President, Federal Programs. The Vice President, Medicare Advantage is accountable for working with the company’s management to define performance criteria and expectations f