Qureos Mentor

Healthfirst (New York)

<div>The Sr Retention Advocate (SRA) is responsible for educating and providing Healthfirst members support to obtain financial entitlements for which they are eligible, to enable members to maintain the highest level of independence both at home and within their communities. The SRA provides education about cost-saving programs, assists Healthfirst members in applying for programs for which they are eligible, and provides follow up support. They are responsible for a cycle of work that requires managing a case from start to finish. This role manages multiple tasks independently with a fast-paced proactive vs. reactive approach to changing priorities. The SRA frequently communicates with members to provide moderately complex information in person and/or by interacting through electronic documentation tools. The SRA works in a paperless work environment requiring daily hands-on administration of multiple electronic Patient Health Information (PHI) databases and security requirement tools such as encryption. These systems include, but are not limited to, TrucareHTML5, RightFax, VoIP, Virtual Work Platforms (VPN), creating pdf files (Adobe Acrobat), and MS Office 360 software (such as Word, Excel and Outlook), Interaction Client, Jabber, and related systems.
Duties &amp; Responsibilities:<ul><li>
Contacts member or primary caregiver by phone or letter to arrange a telephonic or in person interview to assess Medicaid/Medicare/Medicare Savings Program eligibility. Ensures all calls and conversations are conducted in accordance with approved Healthfirst expectations</li><li>
Has full and complete access to patient records and reports as well as to personal/financial profiles and documents, requiring utmost integrity and discretion</li><li>
Serves as an advocate and liaison to maximize the member&rsquo;s support network and to obtain needed services</li><li>
Researches designated tools and platforms concerning eligibility, exclusion, and exemption codes</li><li>
Consults with Human Resource Administration (HRA)/Local Department of Social Services (LDSS) Medicaid staff as needed and report to supervisor any need for HRA/LDSS consultation</li><li>
Tracks the Medicaid/Medicare/MSP status for all members on an ongoing basis to assist that all member entitlements are gained</li><li>
Completes designated application(s) in a timely, organized fashion and assists member or primary caregiver in the completion of the application</li><li>
Assists in collecting all required documents for applications</li><li>
Submits documentation to HRA/LDSS within specified timeframe regarding Medicaid coverage for the member</li><li>
Monitors all applications according to HRA/LDSS/Social Security office/Medicare time frames</li><li>
Documents all client calls /outcomes in database system and spreadsheets</li><li>
Responsible for tracking work, maintaining accurate data, and presenting it, and following up promptly as warranted</li><li>
Prepares/submits monthly reports to Management</li><li>
Additional duties as appropriate or as directed</li></ul>
Ongoing Knowledge &amp; Support<ul><li>
Monitors and maintains awareness and understanding of changes in Medicaid/Medicare/HMO laws, and collaborates and shares information with other team members as appropriate</li><li>
Participates in entitlement training/meetings, as directed</li><li>
Engages in mastering and understanding how the work of the department impacts Healthfirst&rsquo;s overall operations and its members</li><li>
Contributes creative solutions and takes ownership of daily assignments to ensure effective communication and systematic completion of routine and special projects</li><li>
Maintains the highest level of integrity, courtesy, and respect while interacting with clients, other team members, and business contacts</li><li>
Assists with the orientation of new hires to educate them on the model, support enrollment growth and can answer routine questions about the program.</li><li>
Handles other duties as assigned, with the occasional need to work weekends and/or additional hours before or after shift schedule and/or from other HF site locations</li><li>
Experiences managing member information or appointments in a shared network environment using paperless database modules
</li></ul>Minimum Qualifications:<ul><li>
High School diploma or GED from an accredited institution</li><li>
Be able to travel throughout the 5 boroughs, Westchester, Orange, Sullivan, Rockland, and Nassau County</li><li>
Well organized, detail oriented, and able to adapt to procedural and other changes</li><li>
Strong data entry skills and a demonstrated ability to maintain monthly spreadsheets for tracking and statistical purposes</li></ul>
Preferred Qualifications<ul><li>
Associate degree from an accredited institution</li><li>
Prior experience with Medicaid /Medicare/Medicare Savings Program</li><li>
Experience in an inbound and outbound call center within a healthcare environment</li><li>
Prior experience working with an adult or elderly population</li><li>
A competent understanding of integrated care</li><li>
Experience in health insurance, a home care environment, acute, sub-acute, long-term care (LTC) setting, or managed-long term care (MLTC)</li><li>
At least five years in a health plan sales role with a proven record of consistently producing maximum results in a compliant manner.</li></ul>
Compliance &amp; Regulatory Responsibilities: Noted above
License/Certification: N/A 
Hiring Range*:<ul><li>
Greater New York City Area (NY, NJ, CT residents): $58,900 - $80,070</li><li>
All Other Locations (within approved locations): $51,000 - $74,880</li></ul>

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
<ul><li>The hiring range is defined as the lowest and highest salaries that Healthfirst in &ldquo;good faith&rdquo; would pay to a new hire, or for a job promotion, or transfer into this role.</li></ul> 
51000-74880</div>

Field Entitlement Enrollment Specialist

<div>The Manager, Total Cost of Care, will monitor financial performance and provide analytic insights into all products offered within the Healthfirst portfolio. This leader will serve as healthcare economics and analytics subject matter expert, across all areas of medical trend, medical cost savings, provider network informatics, and reimbursement accuracy. The ideal candidate will come from a managed care, medical economics, insurance, actuarial, or hospital background, and will be a results-oriented individual who enjoys working in a fast-paced and challenging environment.
Scope of Responsibilities:<ul><li>
Monitor medical cost and utilization trends, provide concise actionable insight into the root cause drivers, and develop potential remediation opportunities.</li><li>
Develop savings analyses for Medical Economics cost trend reduction initiatives, applying financial modeling expertise and using independent judgement to determine best valuation methods.</li><li>
Prioritization of cost mitigation activities across business areas.</li><li>
Provide actionable data driven analysis to Finance, Claims, Pharmacy, Payment Integrity, Medical Management, Network, and other departments to enable critical decision making.</li><li>
Optimize contractual reimbursement terms and coding across agreements, systematically identifying reimbursement outliers. Assess and work with Network to standardize contractual terms and language across all provider agreements.</li><li>
Evaluate data to identify and root cause of payment integrity issues and lead cross-functional efforts to problem solve.</li><li>
Lead development of tools and processes for efficient operational and reimbursement management of hospitals and physician partners, including unit cost projections.</li><li>
Develop interactive financial models to evaluate the impact of provider reimbursement changes.</li><li>
Support all provider settlement and data reconciliation activities.</li><li>
Development of tools to define profitability dashboards by product.</li><li>
Keep abreast of New York Medicaid and Medicare reforms, reimbursement methodologies, and their impact on Healthfirst and their owner hospital performance.</li><li>
Individual contributor subject matter expert and/or managerial responsibilities.</li><li>
Perform ad hoc analyses.</li></ul>
Minimum Qualifications:
<ul><li>Bachelor&rsquo;s Degree from an accredited institution.</li><li>
At least six (6) years of healthcare analytics experience, with at least three (3) years of experience in contract evaluation, medical economics, medical cost containment, actuarial, healthcare reimbursement model design</li><li>
Extensive knowledge of managed care financial metrics (PMPM, util/k, cost/unit).</li><li>
Experience utilizing healthcare claims data to uncover valuable insights to improve financial performance.</li><li>
Experience with Government and proprietary payor reimbursement methodologies and unit cost management.</li><li>
Experience with SAS or SQL (creates queries and manipulation of data).</li><li>
Extensive experience with Microsoft Excel (building financial models, utilizing pivot tables, VLOOKUP's, index match, and calculated fields).</li><li>
Claims experience including root-cause analysis, system set-up, etc.</li><li>
Ability to work with large data sets.</li><li>
Strong written and verbal communication skills.</li><li>
Experienced in leading a team of analysts.</li><li>
Resourceful and creative in solving complex issues and working corroboratively with others on a solution.</li><li>
Ability to manage projects and project plans within stated timelines.</li></ul>
Preferred Qualifications:
<ul><li>Expertise in key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG&rsquo;s), Ambulatory Patient Groups (APG&rsquo;s), Ambulatory Payment Classifications (APC&rsquo;s), and other payment mechanisms.</li><li>
Understanding of value-based risk arrangements.</li><li>
Experience using Tableau, Python</li><li>
Experience mentoring other team members.</li></ul> 
Hiring Range*:<ul><li>
Greater New York City Area (NY, NJ, CT residents): $103,400 - $149,430</li><li>
All Other Locations (within approved locations): $88,700 - $131,920</li></ul>

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
<ul><li>The hiring range is defined as the lowest and highest salaries that Healthfirst in &ldquo;good faith&rdquo; would pay to a new hire, or for a job promotion, or transfer into this role.</li></ul> 
88700-131920</div>

Total Cost of Care, Manager - Hybrid NY

<div>T he Entitlement Advocate provides Healthfirst Medicare Advantage Plan(MAP), Managed Long-Term Care Plan(LTC), Dual eligible Medicare Plan and Nursing Home members and prospects with obtaining and retaining of financial entitlements for which they are eligible. This enables prospects and members to maintain the highest level of independence both at home and within their communities. Working under the direction of the Entitlement Manager and Team Leads, maneuvers multiple tasks independently with a fast paced proactive vs. reactive approach to changing priorities. Frequently communicates moderately complex information and interacts through electronic documentation tools. This is a paperless work environment requiring daily hands-on administration of multiple electronic Patient Health Information databases and security requirement tools such as encryption.
Duties and Responsibilities<ul><li>
Handle inbound and outbound calls to and from customers to address their needs while adhering to our service level goals.</li><li>
Screen all incoming calls and handles accordingly.</li><li>
Transfer calls to appropriate staff, unit, or department.</li><li>
Assist callers requesting assistance with Medicaid Renewal application, Medicare Savings Program application, and New Medicaid Applications.</li><li>
Outreach Senior Health Partners, CompleteCare, and Life Improvement Plan members according to approved scripts.</li><li>
Research ePACES and/or Marx for Medicaid and Medicare eligibility, exclusion, and exemption codes.</li><li>
Consult with HRA Medicaid staff as needed and report to supervisor any need for HRA consultation.</li><li>
Document all client calls /outcomes in database systems.</li><li>
Schedule appointments to see members/prospects out in the field to assist with Medicaid Issue or restriction code removals or demographic information changes</li></ul>
Growth (Educate and Assess for Medicaid Eligibility):<ul><li>
Educate potential members on Senior Health Partners, Long term care plan benefits answering questions regarding plan&rsquo;s features and benefits as well as go through eligibility and requirement for enrollment.</li><li>
Transfer and connect consumers seeking Long Term Care services with the state broker to complete initial evaluation (New York Independent Assessor).</li><li>
Contact prospects or primary caregiver in person (home or Community Office visit), by phone or letter to arrange an interview to assess Medicaid eligibility.</li><li>
Complete Medicaid applications for New Enrollees and Renewals as needed.</li><li>
Assist prospects to remove Medicaid restriction codes.</li><li>
Assist prospects to Convert Market place Medicaid to Community Medicaid.</li><li>
Facilitate compilation of all required documents. Call, write or in person contacts landlords, employers, bankers, insurance companies, etc. to obtain required documents.</li><li>
Submit documentation to Human Resource Administration or Local Department of Social Services within specified timeframe.</li><li>
Track Medicaid conversions and coverage of all submitted Applications and update status in systems.</li><li>
Serve as the liaison between all parties and acts as Member advocate maximizing the participant&rsquo;s support network and obtaining needed services.</li><li>
Has full and complete access to patient records and reports as well as to personal/financial profiles and documents, calling for the utmost integrity at all times.</li><li>
Serve as a resource for Welcome Enrollment Team, Educating new Enrollees on CDPAS information and forms.</li><li>
Serves as a resource to gather missing EAA forms for Nurse Accepted Enrollments (field pick up).</li></ul>
Retention (Assist with Renewal of Members Medicaid eligibility):<ul><li>
Responsible for contacting and assisting current senior Health Partners and Complete Care members who are due to recertify their healthcare coverage for Medicaid.</li><li>
Contact Senior Health Partners or Complete Care members two months prior to Medicaid expiration date.</li><li>
Conduct home visits and other appointments as needed to complete the application and obtain all required documentation.</li><li>
Complete Monthly Medicaid renewal applications in a timely, organized fashion.</li><li>
Facilitate compilation of all required documents. Call, write or in person contacts landlords, employers, bankers, insurance companies, etc. to obtain required documents.</li><li>
Submit documentation to Human Resource Administration or Department of Social Services within specified timeframe to assure Medicaid coverage for participant.</li><li>
Monitor Medicaid re-certification time frames for each active Medicaid member.</li><li>
Ensure Human Resource Administration and/or Department of Social Services receives the renewal applications and completes re-certification of eligibility timely.</li><li>
Maintain records on every member to show coverage status and timing of re-certification in TrucareHTML5 by opening assessments 2 months prior to renewal due date and closing them out when a member is fully recertified in ePACES.</li><li>
Prepare/submit monthly reports.</li></ul>
Other duties:<ul><li>
Serve as a resource to Care Management Teams, Sales Teams and Nurses for Medicaid and Medicare savings Programs eligibility.</li><li>
Keep up to date on Medicaid and other program issues as well as on changes in Medicaid/Medicare/HMO laws and shares information with other Social Work and Care Team members as appropriate.</li><li>
Participate in relevant entitlement training/meetings.</li><li>
Maintain contact between participant/primary support, business office, social worker, marketing specialists and enrollment specialists to keep parties updated regarding progress of MA and other entitlement applications.</li><li>
Maintain contact between participant/primary support and Medicaid staff of Human Resource Administration as needed.</li><li>
Engage in mastering the Divisions impact on Healthfirst and its Members.</li><li>
Contribute creative solutions and ownership of daily assignments for seamless communication and systematic completion of routine and special projects.</li><li>
Maintain the highest level of integrity, courtesy, and respect while interacting with clients, employees, and business contacts.</li><li>
Assists with orientation of new Hires so they understand the model, support enrollment growth and can answer routine questions about the program.</li><li>
Successfully meet pre and post training and regulatory exams and audit requirements.</li><li>
Arrive at scheduled work site, team meetings, training sessions and events in accordance to departmental policy.</li><li>
Recommend process improvement and advise management of any proposed recommendations that can make a workflow or process more efficient.</li><li>
Handle other duties as assigned with the occasional need to work weekends, additional hours before or after shift schedule and/or from other HF site locations.</li></ul> 
Job Qualifications:
Minimum Qualifications:<ul><li>
High school diploma or GED from an accredited institution</li><li>
Member facing or customer service experience</li><li>
Be able to work 9am-5:30pm schedule</li><li>
Be able to travel throughout the 5 boroughs, Westchester, Orange, Sullivan, Rockland, and Nassau County.</li></ul><ul><li>
Capability to work in a Hybrid Schedule (remote/office/field)</li><li>
Tech Savvy computer skills such as Microsoft Office Suites: Outlook, Excel, Word, PowerPoint.</li><li>
Bilingual</li><li>
Be able to communicate and engage with the leadership team on virtual platforms such as Zoom or Microsoft Teams chat as well as in person</li></ul>
Preferred:
Associate degree from an accredited institution plus 1 year of related work experience including inbound and outbound call center within a healthcare environment.<ul><li><ul><li>
Telephonic experience with frail adult or elderly population.</li><li>
A solid understanding of the value of integrated care.</li><li>
Experience in health insurance, home care environment, acute, sub-acute, long-term care setting, or managed-long term care</li><li>
Have access to a vehicle with valid proof of insurance and be able to travel throughout the 5 boroughs, Westchester, Orange, Sullivan, Rockland, and Nassau County.</li><li>
Experience managing member information or appointments in a shared network environment using paperless database modules</li><li>
Adept at operating within a multi-cultural work environment</li><li>
Bilingual</li></ul>
Prior experience with Medicaid /Medicare Savings Program</li></ul> 
Hiring Range*:<ul><li>
Greater New York City Area (NY, NJ, CT residents): $48,600 - $65,960</li><li>
All Other Locations (within approved locations): $42,200 - $62,400</li></ul>

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
<ul><li>The hiring range is defined as the lowest and highest salaries that Healthfirst in &ldquo;good faith&rdquo; would pay to a new hire, or for a job promotion, or transfer into this role.</li></ul> 
42200-62400</div>

Entitlement Advocate- Bilingual Spanish or Cantonese/Mandarin

Join Healthfirst (New York) and explore 3   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

Healthfirst (New York)

About Company

Field Entitlement Enrollment Specialist

Total Cost of Care, Manager - Hybrid NY

Entitlement Advocate- Bilingual Spanish or Cantonese/Mandarin