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To manage and coordinate incoming grievances and appeals and provide administrative support for the Grievance Unit. Assesses and completes appropriate documentation for tracking and trending date, which may include conducting all pertinent research on a level one grievance in accordance with all established regulatory guidelines. Reviews delegated grievance logs and processes requests for grievance data and reporting.
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To research and resolve provider telephone and written inquiries within established time frames, accurately screen claims, and participate in provider meetings and projects. To accurately research and process paper and electronic medical, outpatient, ancillary, long term care, CHDP, encounter data and paper crossover/other coverage claims within established time frames, applying appropriate program policies related to claims processing and analysis.
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*This position requires a LCSW.
POSITION PURPOSE
To work with a dedicated team to oversee and implement Wellness and Recovery Site Reviews,
provide education to Wellness and Recovery provider sites and to assess and improve the quality
of care delivered by these providers.
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To provide coordination and administrative support to department managers. Performs a variety of general clerical duties, including data entry, report generation, and develops forms and presentations.
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Under direction of the Senior Facilities Manager, this position will assist with the coordination of the maintenance and repair of the building, including electrical, carpentry, pest control, and scheduling of other repairs as needed. This position will be assigned a full range of duties and will receive only occasional instruction or assistance as new or unusual situations arise. This position is fully aware of the operating procedures and PHC’s policies and exercises technical supervision over the less experienced Tech I.
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*This position requires a RN license.
The incumbent utilizes clinical judgement in providing utilization management services. The
focus is to provide high quality, cost-effective care which will enable patients to achieve
maximum medical improvement while receiving care deemed medically necessary. Assists in
determining appropriateness, quality and medical necessity of treatment plans using preestablished guidelines. This position may be assigned cases in long-term care and ancillary,
DME or medical services.
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To assess and complete appropriate documentation for tracking and trending data. Responsible for written responses to all incoming correspondence, including all grievances from members, providers and outside agencies as well as second level and above appeals from members and/or providers for all lines of business.
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To manage and coordinate incoming grievances and appeals and provide administrative support for the Grievance Unit. Assesses and completes appropriate documentation for tracking and trending date, which may include conducting all pertinent research on a level one grievance in accordance with all established regulatory guidelines. Reviews delegated grievance logs and processes requests for grievance data and reporting.
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To prepare, analyze, report, and manage data used for both plan-wide and regional decision making for evaluating performance in key quality measures and the effective use of health plan resources on a routine and ad hoc basis. Works collaboratively with departments company-wide to identify data needs, develop and maintain data queries and tools, and complete accurate reporting to support performance and process improvements. Project/program involvement may include PHC’s Healthcare Effectiveness Data Information Set (HEDIS) reporting initiative, Partnership Quality Dashboard (PDQ), PHC’s provider pay-for-performance programs, and others as assigned.
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Under the direction of the Director of Quality and Performance Improvement (QI/PI), the Manager of Performance Improvement is responsible for key initiatives within the QI/PI Department:
- The Partnership Improvement Academy and its associated programs;
- Strategic, organization-wide improvement initiatives;
- Focused quality improvement projects;
- Internal (PHC staff/departments) quality improvement consultation and training.
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To provide coordination and administrative support to department managers. Performs a variety of general clerical duties, including data entry, report generation, and develops forms and presentations.
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To initiate and coordinate a multidisciplinary team approach to case management. Engages the member/member’s representative in a care plan that assists a member in meeting his/her health and wellness goals. Collaborates, assesses, plans, facilitates, evaluates, and advocates to meet the comprehensive medical, behavioral, and psychosocial needs of the member, while promoting quality and cost-effective outcomes.
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Working with a dedicated and committed team, the Performance Improvement Clinical Specialist (PICS) is responsible for assessing and improving the quality of care provided by the providers serving our members.
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To begin Treatment Authorization Requests (TAR) reviews and perform data entry upon TAR determination by pharmacy staff. Performs eligibility and benefit investigations. Supports pharmacy department with extracting and collecting data for reporting needs. Supports department's administrative needs, and participates in special projects as assigned by pharmacy technician lead, supervisor, and departmental staff.
