Qureos Mentor

Molina Healthcare

Job Description
 
Job Summary
 
Provide prospective and existing members with assistance (telephonically inbound and outbound) completing state required applications, for the purpose of obtaining and maintaining healthcare coverage, and accurate information for eligibility for Medicaid, CHP and Essential Plan. Provide non-clinical reminders (i.e.; product overviews, premiums, gaps in care, care management, member engagement events etc..) and assist as needed with resolving issues, scheduling appointments, conducting outreach to appropriate State entities and resources to ensure member satisfaction, retention initiatives and quality metrics are met.
 
Job Duties
 
<ul>
<li>Pro-actively facilitate outreach (and handle inbound calls) to Molina members regarding their upcoming recertification with the state and healthplan. Educating members on process, qualifications, necessary documentation needed etc; while completeing the required applications and submissions to the State.</li>
<li>Management of individual State dashboards required</li>
<li>Assist and resolve complex member issues related to application errors, immigration status, multi-family enrollment, premiums, eligibility; etc.</li>
<li>Provide non-clinical reminders (i.e. product overviews, premiums, gaps in care, member engagement events etc.)</li>
<li>Facilitate the closure of at-risk care gaps, scheduling appointments, conducting outreach to appropriate State entities, direct toward available resources and care management opportunities; to ensure member satisfaction, retention, and drive plan quality performance.</li>
<li>Responsible for promoting and increasing member enrollments into plan programs (i.e.; Member portal, Rewards Program, etc.)</li>
<li>Assists Medicaid Members in contacting their social worker regarding eligibility issues and follow-up with members to ensure follow through, if allowed by the member’s respective state.</li>
<li>Conduct outreach to retain members that have been identified as late renewals, post terms and potential disenrollments, assist and educate members on next steps and required paperwork.</li>
<li>Accurately and timely documentation of outreach in the appropriate databases.</li>
<li>Collaborate with the leadership team to provide feedback, trends and insights for areas of opportunity for improvement related to technology, process, people, retention and member experience.</li>
<li>Access a number of organizational based platforms and tools for the purpose of inputting and outputting data, related to documenting member care, status, renewal status etc. (such as: Salesforce, CCA, Sharepoint, Excel, Genesys etc)</li>
<li>Attend and assist with in-person community based member retention events</li>
<li>Placement in demonstrated high foot traffic locations, to assist with member in-person interactions may be required. Assist with in-person renewals, eligibility issues, application updates, submission of paperwork etc..</li>
<li>Maintain appropriate certifications and quality scores in compliance with the State and Molina Healthcare.</li>
<li>Some in office trainings, meetings and field work required; will be based on business needs</li>
<li>Other tasks or special projects as required or directed</li>
</ul>
Job Qualifications
 
REQUIRED EDUCATION: 
High School Diploma or equivalent
 
REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES: 
<ul>
<li>2-4 years customer service experience, preferably in a call center environment</li>
<li>Experience communicating with members in a customer service setting and have the ability to assess needs and make thoughtful decisions to help a member</li>
</ul>
REQUIRED LICENSE, CERTIFICATION, ASSOCIATION: 
Must have NYS Certified Application Counselor Certification and/or be able to obtain certification within 60 days of hire date
 
PREFERRED EDUCATION: 
Associate’s Degree or equivalent combination of education and experience
 
PREFERRED EXPERIENCE: 
3-5 years customer service experience in a call center environment
 
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
 
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
 Pay Range: $17 - $38.37 / HOURLY
 <ul>
<li>Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.</li>
</ul>

Specialist, Market Growth & Retention (Remote in NY) - Bilingual – Spanish

JOB DESCRIPTION Job Summary
 
Provides senior level support for member enrollment activities including identifying, interviewing and screening prospective eligible members for Molina health insurance products, assisting with health plan selection and enrollment processes, processing paperwork and ensuring documentation accuracy and follow-up. Also develops and maintains relationships with local community agencies, health care organizations, and county/state agencies that refer potential eligible members, and represents at community-based outreach events to aid enrollment efforts.
 
Essential Job Duties
 
<ul>
<li>Assists with inbound/outbound calls as necessary to support facilitated enrollers with achievement of monthly, quarterly and annual member enrollment goals.</li>
<li>Leads projects and provides support to facilitated enrollers to meet enrollment targets.</li>
<li>Provides support across initiatives, including quality checks to marketing tracking and works with leadership to successfully support facilitated enrollers in enrollment goals/formulate resolutions for enrollers missing enrollment expectations; identifies challenges and communicates accordingly to leadership.</li>
<li>Successfully maintains and/or manages monthly facilitated enrollment calendar.</li>
<li>Demonstrates strong time-management skills including the ability to maintain multi-faceted projects - ensuring both quality and quantity deliverables, while completing job duties and adhering to various objectives with little to no supervision.</li>
<li>Participates in the design and implementation of enrollment-related process improvements within the current facilitated enrollment policies, procedures, services and workflows to improve the customer experience and productivity.</li>
<li>Maintains a high-level of professionalism in all internal/external communications.</li>
<li>Maintains expert knowledge of current enrollment-related processes, rules and regulations of all applicable plans/programs, serves as a resource for implementation, and provides training to facilitated enroller team.</li>
<li>Offers solutions to facilitated enrollment leadership regarding corrective action plans (CAPs), and conducts other quality activities to include policy and procedure and enrollment application reviews.</li>
<li>Performs research assignments as directed by facilitated enrollment leadership which may include but are not limited to sourcing educational resources and best practices for the enrollment team.</li>
<li>Monitors daily enrollment operations, identifies needs related to program tools/resources, and works with facilitated enrollment leadership to meet enrollment function needs and goals.</li>
<li>Meets with prospective members at various sites throughout applicable communities - providing education and support to prospective members navigating complexities of the health care system - assisting with the application process, explaining requirements and ensuring documentation completion.</li>
<li>Demonstrates comprehensive understanding of enrollment processes, best practices, and indications with minor errors.</li>
<li>Maintains high-regard for member privacy in accordance with the Health Insurance Portability and Accountability Act (HIPAA), and internal policies and procedures.</li>
<li>Local travel required.</li>
</ul>
Required Qualifications
 
<ul>
<li>At least 3 years of experience in health care, and/or customer/provider services experience, including at least one year of experience working with state and federal health insurance programs and populations, or equivalent combination of relevant education and experience.</li>
<li>Completion of the New York State of Health Assistors (NYSOH) required training, certification and recertification required for the state of New York.</li>
<li>Must have reliable transportation and a valid driver's license with no restrictions.</li>
<li>Interpersonal/customer service skills.</li>
<li>Data processing and proofing experience.</li>
<li>Attention to detail, organizational and time-management skills, and ability to work independently and meet internal deadlines.</li>
<li>Positive attitude and ability to adapt to change.</li>
<li>Knowledge of managed care insurance plans.</li>
<li>Ability to work with a diverse population, including different ethnicities, cultural backgrounds, and/or underserved communities.</li>
<li>Ability to maintain confidentiality and comply with the Health Insurance Portability and Accountability Act (HIPAA).</li>
<li>Ability to establish and maintain positive and effective work relationships with coworkers, members, providers and customers.</li>
<li>Effective verbal and written communication skills, including presentation skills.</li>
<li>Microsoft Office suite and applicable software programs proficiency.</li>
</ul>
Preferred Qualifications
 
<ul>
<li>Team lead experience.</li>
<li>Previous experience enrolling members into managed care programs/health insurance.</li>
<li>Bilingual – Spanish and English.</li>
</ul>
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
 
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
 Pay Range: $19.84 - $46.42 / HOURLY
 <ul>
<li>Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.</li>
</ul>

Senior Specialist, Benefit Sales (In Field - Spring Valley, NY)

Senior Specialist, Benefit Sales (In Field, Queens, NY)

<div>
 JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.
 
 
 
 Essential Job Duties
 
 
 
 <ul>
 <li>
 Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.
 </li>
 <li>
 Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
 </li>
 <li>
 Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
 </li>
 <li>
 Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.
 </li>
 <li>
 Processes requests within required timelines.
 </li>
 <li>
 Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.
 </li>
 <li>
 Requests additional information from members or providers as needed.
 </li>
 <li>
 Makes appropriate referrals to other clinical programs.
 </li>
 <li>
 Collaborates with multidisciplinary teams to promote the Molina care model.
 </li>
 <li>
 Adheres to utilization management (UM) policies and procedures.
 
 
 </li>
 </ul>
 
 Required Qualifications
 
 
 
 <ul>
 <li>
 At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
 </li>
 <li>
 Registered Nurse (RN). License must be active and unrestricted in state of practice.
 </li>
 <li>
 Ability to prioritize and manage multiple deadlines.
 </li>
 <li>
 Excellent organizational, problem-solving and critical-thinking skills.
 </li>
 <li>
 Strong written and verbal communication skills.
 </li>
 <li>
 Microsoft Office suite/applicable software program(s) proficiency.
 
 
 </li>
 </ul>
 
 Preferred Qualifications
 
 
 
 <ul>
 <li>
 Certified Professional in Healthcare Management (CPHM).
 </li>
 <li>
 Recent hospital experience in an intensive care unit (ICU) or emergency room.
 
 
 </li>
 </ul>
 To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
 
 
 Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
 
 
 Pay Range: $27.73 - $54.06 / HOURLY
 
 
 <ul>
 <li>
 Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
 </li>
 </ul>
</div>

Care Review Clinician (RN)

Job Description
 
Job Summary
 
The Sr Analyst, Risk Adjustment - Predictive Analytics role supports Molina's Risk Adjustment Predictive Analytics team. Designs and develops Suspect, Targeting, and Tracking System to support Molina's Prospective and Retrospective Interventions. Assist with research, development, and completion of special projects.
 
Knowledge/Skills/Abilities
 
Assist Risk Adjustment Data Analytics Leaders in Prospective and Retrospective Intervention Strategy Analytics along with corresponding tracking of progress and impact of such interventions.
 
Development and QA of ad-hoc as well as automated analytical as well as Reporting modules related to Risk Adjustment for Medicaid, Marketplace and Medicare/MMP.
 
Assist Risk Adjustment Data Analytics Leaders in designing and developing Automated Suspect and Target/Ranking Engine for all line of businesses.
 
Analysis and reporting related to Managed care data like Medical Claims, Pharmacy, Lab and related financial data like risk score, revenue and cost.
 
Calculate and track risk scores for all intervention outcome and for overall markets and LOB.
 
Work in an agile business environment to derive meaningful information out of complex as well as large organizational data sets through data analysis, data mining, verification, scrubbing, and root cause analysis.
 
Conduct root cause analysis for business data issues as assigned by the team lead.
 
Analyze data sets and trends for anomalies, outliers, trend changes and opportunities, using statistical tools and techniques to determine significance and relevance. Utilize extrapolation, interpolation and other statistical methodologies to predict future trends in cost, utilization and performance. Provide executive summary of findings to requestors.
 
Assist with research, development and completion of special projects as requested by various internal departments, or in support of requests from regulatory agencies, contracting agencies, or other external organizations.
 
Track, Facilitate and Manage changes in the Datawarehouse platform and perform transparent upgrades to analytic reporting modules to ensure no impact to the end users.
 
Conduct preliminary and post impact analyses for any logic and source code changes for data analytics and reporting module keeping other variables as constant that are not of focus.
 
Develop oneself as subject matter expertise by following CMS/State regulations related to Risk adjustment Analytics.
 
Job Qualifications
 
Required Education
 
Bachelor's Degree in Computer Science, Finance, Math or Economics or equivalent discipline
 
Required Experience
 
3-5 Years of experience in working with data mapping, scrubbing, scrapping and cleaning of data.
 
3-5 Years of experience in Managed Care Organization executing similar techno functional role that involves writing complex SQL Queries, Functions, Procedures and Data design
 
3-5 years of experience in working with Microsoft T-SQL, SSIS and SSRS.
 
Familiarity with Data Science Techniques and languages like Python and R programming would be an added advantage.
 
3-5 Years of experience in Analysis related to Risk Scores, Encounter Submissions, Payment Models for at least one line of business among Medicaid, Marketplace and Medicare/MMP.
 
3-5 Years of experience in Prospective/Retrospective/Audit targeting Analytics and Reporting.
 
3-5 Years of experience in working with increasingly complex data problems in quantifying, measuring, and analyzing financial/performance management and utilization metrics.
 
3-5 Years of experience in Statistical Analysis and forecasting of trends in medical costs to provide analytic support for finance, pricing and actuarial functions
 
PHYSICAL DEMANDS
 
Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.
 
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
 
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
 Pay Range: $83,252 - $155,508 / ANNUAL
 <ul>
<li>Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.</li>
</ul>

Senior Analyst, Risk Adjustment - Predictive Analytics (Remote)

Join Molina Healthcare and explore 5   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.

Molina Healthcare

About Company

Specialist, Market Growth & Retention (Remote in NY) - Bilingual – Spanish

Senior Specialist, Benefit Sales (In Field - Spring Valley, NY)

Senior Specialist, Benefit Sales (In Field, Queens, NY)

Care Review Clinician (RN)

Senior Analyst, Risk Adjustment - Predictive Analytics (Remote)