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To maintain accurate provider information by entering all necessary data elements into several database systems. Reviews forms for completeness and researches discrepancies. Ensures all information is updated timely within departmental standards. Responds to routine provider telephone inquiries via telephone and email.
The Senior IT Project Manager is responsible for the successful delivery of large-scale, complex projects often involving multiple internal and external stakeholders through all phases of the SDLC. The Senior IT Project Manager helps set and follow clear project management standards including project plans, change controls, risk management, and other project management documents on given strategic initiatives. The Senior IT Project Manager assists in developing standards, managing the enterprise IT project priority list with IT Directors, and assists in IT Steering Committee meetings if needed. This position reports to the Director of IT Strategic Initiatives.
To assist in the development, implementation, and maintenance of professional, facility, and ancillary contracts for the PHC provider network. The Contracts Coordinator II is responsible for initiating contracts and supporting daily contracting activities as directed by Manager.
To effectively communicate and implement project management methodologies required to
drive the planning, implementation, and tracking of projects through all aspects of the project
lifecycle. Project Managers are responsible for the planning, procurement and execution of a
project. Projects are time bound with a distinct start and end point. Ensure accuracy,
consistency, and thoroughness of projects. In addition to the Project Manager I duties, the
Project Manager II has a higher level of experience, more autonomy, exercises independent
judgment, and conducts business analysis and analytics to develop project impact and return on
To plan, organize, manage, and implement projects.
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.
To develop and implement long-term quantitative analysis strategies to meet NCQA standards for reporting. Identify quality gaps, implement reporting processes in order to track grievances concerning access to care, appeals trending, enhance current systems, define and prioritize high-value quality products and manage regulatory reports to completion. Develop standardized testing methods which facilitate the quality checking process.
Under direction of the Manager or above, provides supervision of the assigned Grievance staff, and assists in the day-to-day operations in the Grievance Unit by providing leadership, direction, and support to Lead Grievance Coordinators, Grievance Coordinators, and Grievance Resolution Specialists.
The Senior Health Data Analyst contributes to the overall success of the organization by developing analytic solutions that support activities related to health services utilizationmanagement, care coordination, quality improvement and population health. Through analyzingpatient claims, member enrollment, and other data, the Senior Health Data Analyst participates in identifying progress, performance and opportunities for improvement on programs, quality of care, patient experience, and other metrics. The Senior Health Data Analyst requires athorough understanding of healthcare data and workflows, combined with an extensive experience creating large data sets, conducting statistical data analysis (SAS), and using BI tools (Tableau).
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.
To provide clerical and general office support for department functions.
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.
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.
To support the financial reporting and analytical processes by analyzing actual performance against budget for profit and loss information and other data in order to identify, evaluate, and communicate drivers of performance. Develops, coordinates, and is directly involved in projects and activities that help drive business decisions, affect provider reimbursement programs such as P4P, and provider capitation configuration. Works collaboratively with staff in Finance/Accounting in the ongoing analysis and reporting of all aspects of the income statement and other operating metrics.