Member Relations Compliance Rep - JHP

Job Details

Job Description

Primary Responsibilities:

• Serve as a point of contact for all internal departments and vendor for CMS, DHS, and OOC communications including HPMS issued guidance, and other relevant regulatory and sub-regulatory guidance.
• Review of CMS, DHS, OOC and NCQA guidance and how it applies to Member Relations and related first tier-downstream entities.
• Development of related processes and policies.
• Monitoring and documentation of operational compliance components.
• Effectively communicate with various internal management teams to ensure compliance with contractual/regulatory requirements.
• Act as a representative of Jefferson Health Plans at internal and external meetings/workgroups, etc., as required or requested.
• Educate staff on compliance updates and how it applies to day to day operations for areas of responsibility.
• Assist with data collection and organization for Medicare, CHIP, NCQA and Medicaid audits, internal - external.
• Maintain records to demonstrate timely completion of all internal requests.
• Assist management in reviewing, clarifying and disseminating CMS, DHS, OOC and NCQA guidance to appropriate Jefferson Health Plans Member Relations staff and associated vendors.
• Report on trends and issues that impact the Member Relations Department staff.
• Participate in appropriate staff meetings.
• Responsible for the documentation and creation of operating procedures.
• Identify Training gaps/needs.
• Provide recommendations and feedback.
• Call listening to monitor for compliance and standard process.
• Act as an interdepartmental liaison.
• Coordinate cross-functional and interdepartmental initiatives.
• Facilitate training sessions and vendor oversight meetings.
• Mock audit activity as needed.
• Test calls- including the monitoring/documentation of quality results.
• Monitoring of call center performance.
• Track performance outcomes and improvement activities.

• May perform other duties as assigned.

Education:

• Bachelor's degree preferred or equivalent work experience.

Skills/Abilities:

• 2-3 years of Medicare and Medicaid operational experience.
• Preferred demonstrated experience across multiple Medicare, Medicaid, OOC and NCQA disciplines i.e. CTM, call center, grievances, and monitoring.
• Excellent written and verbal communication skills.
• Ability to manage multiple tasks and adhere to deadlines.
• Bilingual a plus, but not necessary.
• Ability to work independent of direct supervision, but also must be able to meet and exceed deadlines for close turnaround timeframes.
• Proficiency in Departmental Information Systems including DPW, Member Health Information System and Pharmacy Systems.
• Must possess ability to provide continual updates to management on all issues, bringing those with potential impact to the attention of management immediately.
• Ability to maintain open, amicable communication with government entities, and Health Partners management, in an effort to ensure development of a "partnership" relationship.

Work Shift

Worker Sub Type

Primary Location Address

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.