Net developer Jobs in Syracuse, NY

LTSS/DUALs SN Project Coordinator

This position supports the workflow of the Long-Term Support and Services (LTSS) and Duals Special Needs (DSNP) department. Depending on the specific tasks assigned, the LTSS/DUALs SN Project Coordinator provides administrative support for DUALs and/or LTSS staff. This position acts as an administrative support resource for staff regarding members' specific contract benefits; consistent with products, policies and procedures and related health plan functions such as member services, claims, and the referral process, as well as functions related to legislative and federal regulatory mandates related to the Health Plan. The position also supports member centric care within LTSS/DUALs programs.

Essential Accountabilities:

Level I:

• Review / prep clinical case for clinical staff.
• Navigates and utilizes corporate applications; core claims and membership system, intranet and related links to provide support to the division.
• Serves as the primary contact for providers regarding authorization, information requests, claim inquiries and benefits. Provides triage assistance to internal subject matter experts, as needed.
• Prepares and assists in handling member and provider correspondence related to authorization detail, disease conditions and/or care management program services. Assures accuracy and timeliness of processing.
• Assesses benefit coverage, interpreting individual eligibility, provider and subscriber agreement parameters, and required criteria.
• Validates relevant UM/BH/MCM/Quality voice and email inboxes and/or Stored Information retrieval (SIR) queues throughout day for messages, potential care management referrals, authorization requests and clinical documentation.
• Answering and responding to telephone calls, e-mails, etc. as long as they are non-clinical in nature.
• Ensures timely, accurate inquiry resolution while maintaining consistent policies, regulatory compliance, operational support, and a culture of continuous improvement.
• Assist with completion of Health Risk Assessment and any additional follow ups required.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Level II (in addition to Level I Accountabilities)

• Performs intake assessment and sends to appropriate queues or assigns to staff in appropriate service area. Provides preliminary support to multiple levels of providers (and others as needed), including but not limited to physicians, skilled nursing facilities, mid-level providers and members.
• Extracts, sorts and distributes reports from internal and external databases, as determined based on designated criteria, to appropriate internal individual/department.
• Identify members, through a systematic approach, who would benefit from care management or have previous UM/BH activity. Apply care management criteria to determine member appropriateness for care management programs (systems researched may include care/utilization management system, claims and membership system, HCS, and/or MedAi). Research claims history and related services for identified members (medication refills, identification of in and out of network providers, etc).
• Communicates to the members and service providers according to regulatory agency requirements and/or organizational guidelines.
• Produces LTSS/DUALs departmental statistics on a daily and as needed basis for department related metrics: case and review timeliness, workflow volumes, and case assignments.
• Prioritizes work and provides instruction, advice and guidance to more junior staff as it relates to the assigned unit's processes, procedures, and business systems.
• Conducts post-discharge follow-up and screening calls, coordinates home visit scheduling
• Performs member home visits as needed to support care management.
• Serves as an intermediary between member, department staff and management to alert supervisor of potential problems.
• Collaborates with other internal departments to ensure end-to-end process for authorizations and care management referrals is accurate and complete.
• Schedules initial telephone call appointments with members and care managers, as requested.
• Provides administrative support to the grievance and appeals process within the LTSS/DUALs department.

Level III (in addition to Level II Accountabilities)

• Assists supervisor with control and monitoring of inventory levels of assigned department according to established priorities and performance standards.
• Assists supervisor with monitoring and evaluating workflow to ensure timeliness and unit standards are met. Provides reporting, analysis and recommendations to unit management based on day-to-day and observed experience.
• Assists in updating departmental policies, procedures and desk-level procedures relative to the department functions. Identifies and develops processes and guidelines for performance improvement, productivity and efficiency gains.
• Handles complex issues, escalated customer questions, high maintenance or priority customers for the assigned business unit, high dollar/high-cost member investigation.
• Assesses staff and unit training needs and reports this information to the supervisor. Assists with onboarding of new staff.
• Identify eligibility and coverage and assisting other staff and other areas within the company with related inquiries.
• Collaborates with internal departments regarding changes in processes/systems and identifies problems and recommends logical and effective solution.

Minimum Qualifications:

NOTE:

We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities

Level I

• Minimum one (1) year of experience working in an insurance company, Health Plan customer service or claims department, medical care/medical assistant setting, or LDSS required.
• Working knowledge of medical terminology.
• Demonstrate proficiency with Microsoft Office Suite.
• Excellent oral and written communication skills.
• Demonstrated organizational and interpersonal skills; able to manage multiple tasks under pressure.
• Ability to utilize department specific applications and software: care management system and department libraries.
• Ability to utilize engagement strategies to connect with population served (i.e. motivational interviewing, etc.)
• Attention to detail.

Level II (in addition to Level I Qualifications)

• Minimum of three (3) years' work experience working in an insurance company or medical care setting required.
• Ability to develop and apply in-depth knowledge of complex rules, such as those of the authorization process, care management systems and processes, departmental policies and procedures, product lines, and contract benefits.
• Broad understanding of multiple areas of the company and willingness to develop collaborative solutions to achieve a better end-to-end process.
• Ability to recognize sensitive issues and/or significant areas of concern and when to escalate to management.
• Demonstrated ability to lead committee activity and support newer team members.
• Demonstrated exceptional customer service skills.
• Demonstrated subject matter expert knowledge and experience with HCS, and associated LTSS/DUALs databases, requirements, workflows and technology.

Level III (in addition to Level II Qualifications)

• Minimum of five (5) years of experience working in an insurance company, LDSS or medical care setting required.
• Two (2) years LTSS/DSNP/MLTC experience or working with MLTC, DUALs or LTSS populations preferred.
• Demonstrated thorough knowledge and understanding of sources of information about LTSS and/or DUALs including CMS/Medicaid contracts and MLTC, DUALs, LTSS Policies and procedures.
• Knowledgeable in multiple systems and/or processes that allow for effective and efficient identification of data or process issues to resolve related issues.
• Ability to precept new staff, take on new challenges, flexibility in work assignments, and participation in meetings and projects as assigned.
• Demonstrated presentation skills.
• Working knowledge of claims payment process, including coding principles preferred.

Physical Requirements:

• Ability to work prolonged periods sitting and/or standing at a workstation and working on a computer.