Job Description

Location: Novato

Employment Status: Full Time

General Summary

Under the direction of the UM Medical Director and the UM Manager, this position is responsible for analyzing clinical information submitted by medical providers by evaluating the medical necessity, appropriateness and efficiency of the medical services, procedures and facilities use for commercial and Medicare members. Evaluations are completed using evidence-based guidelines created for non-physician clinicians establishing medical necessity.  These duties may include assignments to all venues requiring utilization management such as pre-authorization for inpatient and outpatient services, concurrent inpatient and observation hospital stays, Skilled Nursing Facility (SNF) stays, ambulatory services and other services as required.  This job may coordinate utilization management and case management activities.  The Utilization Management nurse is knowledgeable about the CA Nurse Practice Act, NCQA, MCG (Milliman Care Guidelines), the Center for Medicare and Medicaid, DMHC and timeliness rules and pertinent state and federal regulations.

Principle Accountabilities

• Review routine and urgent requests for service authorization on assigned patients in accordance with NCQA timeliness standards and health plan benefit structure
• Prepares and presents cases for UM Medical Director review in a concise, objective and organized manner.
• Educates and supports members in accessing care using their HMO and Medicare Advantage benefits as indicated
• Identifies and refers patients to disease management, wellness programs and community resources whenever relevant.
• Utilizes the nursing process and critical thinking skills to provide oversight of services and evaluation of service options

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Job Requirements

Minimum Requirements

Education:

• Completion of Diploma or Associates Degree in Nursing
• Bachelor’s Degree in the Science of Nursing Preferred

Experience:   

• Minimum three to five years of clinical experience.
• Minimum one to three years in a managed care or health plan environment

Licensure:

• Current and unrestricted License from the California Board of Nursing

Knowledge, Skills, and Competencies 

• Ability to understand and facilitate communication among team members, patients, families, physicians and medical office staff.
• Ability to communicate effectively with contracted health plans and meet required turn around times
• Excellent clinical judgment, critical thinking skills and independent problem resolution
• Knowledge of managed care principles, HMO and Risk contracting arrangements
• Ability to organize and prioritize workload
• Proficient typing skills with competency in working with Microsoft Word, Excel, Outlook, varied EMR platforms.  Prior experience with Health Care Management/authorization software preferred
• Excellent telephonic customer service skills
• Flexibility to learn and work in various RN assignment within the department

Ability to work with and provide sensitivity to a variety of culturally-diverse communities

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Job Description

Location: Novato

Employment Status: Full Time

Position Summary
This is a professional level position which provides project management and administrative support to the Chief Strategy Officer (CSO) in the areas of strategy, new business development, marketing, public relations, and communications.

Reporting Relationship: Reports directly to the Chief Strategy Officer

Principal Job Duties

Project Management
The Project Manager Project management duties include, but are not limited to:
•Developing communication plans, timelines and work schedules to meet established goal(s);
•Assembling and meeting regularly with the project team, i.e., individuals from all areas/departments who share responsibility for the project;
•Identifying key project milestones and responsible parties;
•Maintaining project plan document, spreadsheets and files, and making such materials available to project team members;
•Following-up on assigned deliverables for responsible persons, and identifying any issues orconcern that may be impacting the person’s ability to meet the goal on time;
•Scheduling and facilitating project plan meetings, materials and communications; and,
•Participating as an accountable party for assigned duties and deliverables.
Handles administrative duties including but not limited to, scheduling appointments and meetings, preparing and disseminating meeting minutes and assignments, reviewing and proofreading documents, drafting and editing documents that support project management responsibilities.
Strategy
This role supports the CSO with the development, planning and execution of the organization’s strategic initiatives. Provides leadership and support to foster departmental initiatives and improvement plans that are cohesive with long-term company goals. As needed, communicates and collaborates internally and externally to ensure strategic initiatives are understood, implemented and sustained.
New Business Development
Assists the CSO with the development of new business opportunities and relationships for the organization, including but not limited to:
•Researching potential business partners to determine organizational and financial strength, culture and community perceptions
•The preparation of business presentations, plans and proposals
Strategy & Communications Project Manager
•Meeting and communication with prospective business partners
•Attracting and retaining new and existing business partners to generate new business
Marketing
Is responsible for assisting the CSO in developing and implementing the internal and external marketing plans for the Meritage organization, its services, service lines and overall capabilities. Serves as a liaison between company and Marketing resources and vendors. Assists the CSO in developing, growing, and monitoring progress with new products/services. Additional marketing activities may include, but are not limited to social media, Search Engine Optimization (SEO), Website design and maintenance, and advertising.
Public Relations & Communications
Assists CSO in reviewing any external facing materials or communications and oversight of the company brand and compliance with established standards. Drafts Press Releases and assists in developing presentations for community and industry events. Designs and coordinates the disseminations of materials for internal and external communications. Serves as a liaison between company and Public Relations vendors.
Plans, organizes, coordinates, promotes and facilitates special events. Schedules and maintains communication with speakers, vendors and participants. Coordinates and monitors event timelines. Reviews and analyzes evaluations. Assists in the preparation of a variety of publications, materials and programs for events.

Works effectively, collaboratively and regularly with the other members of the Meritage team to uphold the mission, vision and values established by the organization (see attached).

Other duties as assigned by the CSO which support and help strengthen the Meritage organization and its goals, objectives and strategic partnerships.

Go to application

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Job Requirements

Knowledge, Skills and Abilities
•The Project Manager should have a proven track record of successfully managing multiple projects,priorities and meeting deadlines.
•Demonstrated skill and experience in producing high quality documents and materials.
•Possess a highly professional, positive, and composed demeanor and have the ability to positively and effectively represent and “sell” the Company.
•Must be highly organized, detail oriented, polished and diplomatic in his/her interactions with others within and external to the company.
•Must have experience, a high comfort level, and project confidence with presenting to large groups of people.
•Possess the ability to manage projects independently as well as with a team, and to know when each work style is required by the work at hand.
•Have strong critical thinking, problem solving and creative thinking skills. Be adaptable to and comfortable with change and skilled at managing priorities in a fast paced and changing work environment.
•Must be able to comfortably and effectively work and communicate with a variety of personalities,work styles and constituencies, e.g., Physicians, providers, executives, analysts, vendors, and front-line staff.
•Additional skills and competencies include excellent verbal, writing, grammar and editing skills,commitment to excellence, and strong time management abilities.

Education, Experience and Qualifications
•A Bachelor’s degree in business, healthcare, administration or related field; Project Management Certification preferred.
•A Graduate degree in any of the above fields strongly preferred.
•A minimum of 3 to 5 years of work experience in a project management role, in healthcare preferred, or an equivalent combination of education and experience.
•Comfortable working knowledge of marketing, public relations and communications.
•Strong skills and experience working with office-based software applications, including but not limited to Word, Excel, Publisher, and PowerPoint.

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Job Description

Location: Novato

Employment Status: Full Time

• Prepare relevant data analyses and reporting that helps departments meet their objectives and supports the business initiatives of the organization.
• Conduct ad-hoc analyses to identify strategic opportunities for improving patient care, increasing revenue, reducing costs, and finding operational efficiencies.
• Develop reporting of clinical, financial, and operational metrics for stakeholders; present and communicate findings.
• Maintain and improve upon data and reporting capabilities by developing new systems, processes, reports, and tools to deliver impactful and actionable insights that drive decision making.
• Gather, research and analyze clinical and claims data to help measure and improve performance against industry standards. Identify areas for improvement and opportunities for increasing incentive payments.
• Work with physician groups and independent practices across the Meritage Network to establish/improve quality data feeds for reporting to Meritage data vendors and health plans.
• Prepare productivity reports for related Medical Group physicians in order to ensure they are paid appropriately according to their contracts. Conduct ad-hoc analyses of productivity data per Medical Group requirements.
• Assist with the annual quality audit for the Align Measure Perform program. 

Core Requirements

• Proficiency with data management and analysis tools such as: Microsoft Access, Power BI, and Excel
• Ability to quickly learn and master new software systems
• Experience working with relational databases with complex architecture and table structure
• Ability to develop and support in-depth reports that show nuanced and complicated clinical data, including the ability to teach end users how to interpret content
• Excellent written and verbal communication skills, including designing and presenting reports to internal and external groups
• An understanding of basic corporate finance principles
• Critical thinking and independent problem resolution skills
• Ability to prioritize workload to meet deadlines for short and long-term goals with competing timeliness.

Software and Tools

• High proficiency with Microsoft Excel
• Proficiency with or the ability to learn to work in a Microsoft Office environment: Outlook, PowerPoint, Visio, Excel, Word, Power BI, OneNote, etc.
• Proficiency with or the ability to learn to use project management and collaboration software: Asana, SharePoint

Go to application

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Job Requirements

Education and Experience

• Ideally, 2+ years of data analysis experience
• Ideally, a background in at least one of the following areas: Risk Adjustment, HMOs, ACOs, Health Plans, Utilization Management, Case Management, Pay for Performance, 5 Star, etc.
• Bachelor’s degree or related study in one of the following areas: Statistics, Computer Science, Data Science, Informatics, Population Health, Healthcare Administration, Finance, Economics, etc., or a combination of education and experience.
• Curiosity and willingness to learn

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Job Description

Location: Novato

Employment Status: Full-Time

The Utilization Management Coordinator serves as a liaison between Meritage Medical Network, our contracted health plans, Network physicians and Members. The incumbent is responsible for intake of all requests for medical services. Must have the ability to understand and use set criteria and approve specific services within the related UM system.

Principle Duties and Responsibilities:
• Ensure prompt, accurate data entry of Authorization requests into the MedVision system
• Utilize knowledge and experience to analyze contractual or administrative issues related to the requests.
• Identify additional information needed and ability to research and understand Policy benefits and criteria
• Accurately identify when and how to refer cases to appropriate clinical personnel or take other actions.
• Follow strict guidelines to ensure all work meets ICE standards for accuracy, timeliness, quality and compliance with federal, state and accreditation regulations.
• Coordinate with other insurance coordinators and the medical review staff.
• Consistently meet department productivity and performance metrics.
• Contribute to the efficiency of the department by being flexible and cross-trained on other functions.

Go to application

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Job Requirements

Qualifications:
• 1 – 2 years of related experience.
• Familiarity with Medical terminology required
• Familiarity with insurance billing and terminology preferred
• Managed Care experience, preferred.
• Knowledge of CPT and ICD codes.
• Strong data entry skills.
• Excellent interpersonal skills, including phone, verbal, and written communication.
• Ability to cope in a fast-paced production environment
• Demonstrated knowledge of customer service skills when responding to questions and other inquiries from internal and external customers.
• Strong computer skills with demonstrated proficiency in Excel, Outlook and other Microsoft Office applications.
• Must be organized and detail oriented.

Education:
• High School Diploma required.
• Coding certificate or Medical Assistant graduate desirable

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