Job Description

Location: California

Employment Status: Full time

POSITION SUMMARY:

• Prepare relevant data analyses and reporting that helps departments meet their objectives and support 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.
• Consistently demonstrate behaviors, conduct and communications that support Meritage’s Practices and Values of Accountability, Diversity, Integrity and Respect for others, and will seek to influence these behaviors in others.
• Continuously endeavors to “raise the bar” of performance and teamwork through a focus on Innovation, Collaboration, Equality and Compassion.

Job Requirements

REQUIREMENTS & QUALIFICATIONS:

• 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 equivalent combination of education and experience.
• 3+ years of data analysis experience.
• High proficiency with data management and analysis tools such as SQL, Power BI, Excel (intermediate).
• Background in at least one of the following areas preferred: Risk Adjustment, HMOs, ACOs, Health Plans, Utilization Management, Case Management, Pay for Performance, 5-Star, etc.
• Proficiency with or the ability to learn to work in a Microsoft Office environment: Outlook, PowerPoint, Visio, Excel, Word, Teams, Power BI, OneNote, etc.
• Proficiency with or the ability to learn to use project management and collaboration software: Asana, SharePoint.
• Curiosity and willingness to learn.
• 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 the content..
• Excellent written and verbal communication skills, including designing and presenting reports to internal and external group.
• 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 timelines.

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Job Description

Location: Novato, CA

Employment Status: Temp

Temporary Position 

POSITION SUMMARY:
Is responsible for performing numerous clerical and coordination support functions within the Claims department to ensure efficient departmental workflow and to meet applicable regulatory claims processing requirements.

ESSENTIAL JOB FUNCTIONS:
• Responsible for all incoming mail.
• Initial triage and redistribute misdirected claims to the Health Plans or other Payors.
• Responsible for daily scanning of incoming claims.
• Reconciliation of qualifying paper claims.
• Identify and routes incoming checks to the appropriate department.
• Assist with clerical exception reports.
• Batch, file, and retrieve completed claims forms.
• Assists with preparation of weekly check runs.
• Assist with claims related eligibility issues.
• Consistently demonstrate behaviors, conduct and communications that support Meritage’s Practices and Values of Accountability, Diversity, Integrity and Respect for others, and seeks to influence these behaviors in others.
• Continuously endeavors to “raise the bar” of performance and teamwork through a focus on Innovation, Collaboration, Equality and Compassion.
• Models professional work standards and behaviors to maintain and strengthen a professional working atmosphere and strictest confidentiality within the department and with other Meritage internal and external customers and work partners.
• Is accountable for work performed by self, works to develop and maintain trusting working relationships with others, and seeks to continuously learn from errors and experiences, as well as new developments in job specific Claims administration and operational areas.
• Adopts, incorporates, is mindful of, and otherwise supports Meritage’s overarching annual and longer-term strategic business goals and objectives while performing work duties, special projects and other duties as assigned within or outside of the Claims Department .
• Performs other than normally assigned duties and projects, as directed, and required, within and outside of the Call Center department to support Meritage’s overall business needs, goals, and objectives.

Job Requirements

REQUIREMENTS & QUALIFICATIONS:
• High School diploma and 1-2 years of related healthcare work experience, or equivalent combination of education, experience, and related skills
• Experience with office-based computers, keyboards, and related equipment such as: printers, fax machines, etc.
• Microsoft Office Suite applications: Word, Excel, PowerPoint, etc.
• Experience working with various electronic medical records systems and databases and confidential handling of patient PHI
• Strong written, verbal and listening communication skills
• Professional demeanor with a positive, approachable, and kind affect
• Ability to exercise cognitive thinking skills and process new information to incorporate into current workflow and practices
• Demonstrated ability to work in a fast-paced environment with rapidly changing and competing priorities
• Proficiency in medical terminology, medical/hospital coding, claims adjudication

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Job Description

Location: Novato, CA

Employment Status: Full time

POSITION SUMMARY:
The Payroll Administrator is responsible for handling critical aspects of the payroll cycle and assisting the Chief Financial Officer with related tasks, including bi-weekly and semi-monthly payroll for 2 entities, processing and delivery, as well as monthly reporting and forecasting. In addition, the Payroll Specialist may assist in general administration tasks as a member of the overall Finance Department.

• Process payroll for multiple entities.
• Learn and master current payroll and timekeeping software system to track relevant data and assist in time and salary reporting.
• Ensure proper deduction for and submission of garnishments and other levies.
• Document and update procedures as necessary, providing recommendations for continuous process improvement.
• Train new employees and managers on time reporting and approval.
• Assist with payroll-related state and local filings.
• Consistently demonstrate behaviors, conduct and communications that support Meritage’s Practices and Values of Accountability, Diversity, Integrity and Respect for others, and will seek to influence these behaviors in others.
• Continuously endeavors to “raise the bar” of performance and teamwork through a focus on Innovation, Collaboration, Equality and Compassion.
• Perform other duties as assigned.

Job Requirements

QUALIFICATIONS & REQUIREMENTS:
• Minimum 2 years of payroll accounting experience, preferably in a professional services environment.
• Bachelor’s degree in Finance or Accounting preferred; or equivalent combination of education and experience in payroll processing and management.
• Multi-state processing experience and Fundamental Payroll Certification (FPC), or similar, designation preferred.
• California Wage and Hour knowledge and experience.
• Certified Payroll Processor (CPP) desired.
• W2 experience desired.
• Highly developed organizational skills and unwavering attention to detail.
• Working knowledge of medium-sized employer payroll system required (e.g. APS, ADP, etc.)
• Working knowledge of MS Dynamics Business Central preferred.
• General computer application proficiency with all Microsoft Office applications (Outlook, Teams, Word, Excel, PowerPoint) as well as Adobe Acrobat.
Updated 11/2022
• Strict attention to privacy issues and absolute discretion required.
• Capacity to prioritize a variety of tasks and heavy volume, deadline-focused work.
• Strong analytical skills and an extreme attention to detail mindset.
• Strong customer service orientation; comfortable working independently with all levels of employees.
• Ability to work independently as well as inter- and cross-departmentally.
• Excellent oral and written communications skills within a diverse office environment.
• Mature, accountable and cooperative.

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Job Description

Location: Novato, CA

Employment Status: Full time

Position Summary:
The Meritage Call Center Representative provides prompt, accurate and courteous responses to written and telephonic inquiries. These inquiries encompass numerous contacts and originate from subscribers, members, physician offices, and Health Plans; and typically involve a variety of issues including benefits, pricing, claim rejections, authorizations, and claim status.

Essential Job Functions:
• Ability to research and accurately resolve problematic claim situations.
• De-escalate situations involving dissatisfied customers, offering patient assistance and support.
• Provide full customer service where you could accept inbound or might be calling out to provide follow up on a concern.
• Maintain customer accounts and information.
• Respond to customer inquiries with compassion and active listening and support the best solution in an efficient manner.
• Consistently demonstrate behaviors, conduct and communications that support Meritage’s Practices and Values of Accountability, Diversity, Integrity and Respect for others, and seeks to influence these behaviors in others.
• Continuously endeavors to “raise the bar” of performance and teamwork through a focus on Innovation, Collaboration, Equality and Compassion.
• Models professional work standards and behaviors to maintain and strengthen a professional working atmosphere and strictest confidentiality within the department and with other Meritage internal and external customers and work partners.
• Is accountable for work performed by self, works to develop and maintain trusting working relationships with others, and seeks to continuously learn from errors and experiences, as well as new developments in job specific Call Center administration and operational areas.
• Adopts, incorporates, is mindful of, and otherwise supports Meritage’s overarching annual and longer-term strategic business goals and objectives while performing work duties, special projects and other duties as assigned within or outside of the Call Center.
• Seeks to continuously learn from errors and experiences, as well as new developments in job specific areas.
• Performs other than normally assigned duties, as directed, and required, within and outside of the department to support Meritage’s overall business needs, goals, and objectives.
• Initially and on an ongoing periodic basis, spends time with each HR staff member, payroll and other identified internal staff to gain an understanding of their job duties, challenges, and to better identify and support an effective continuum of workflow with Meritage, to support continuous process improvement and remove any roadblocks impacting productivity.

Job Requirements

Education and Experience
•High School Diploma or GED required.
•3-4 years previous claims customer service experience or call center.
•Familiarity of medical terminology preferred.
•Prior experience with medical coding (ICD10, CPT) preferred.
•Microsoft Office Suite applications: Word, Excel, PowerPoint, etc.
•Customer service experience in a healthcare related field- HMO experience preferred.

Required Skills, Knowledge and Abilities
•Multi-task and keyboard while researching, following up, resolving, and documenting telephonic inquires.
•Knowledge of claim benefit interpretation/benefit adjudication logic.
•Must be proficient in problem solving and detecting trends.
•Excellent communication skills – meaning you can adapt to new and different situations, read the behavior of others, have difficult conversations with ease and defuse and resolve conflict.
•Must be able to read and interpret all types of authorization, medical claim forms and member benefit plans.
•Integrity to follow HIPAA guidelines on maintaining patient privacy.
•Ability to adapt and excel in a fast-paced work environment.

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Job Description

Location: Fresno, CA

Employment Status: Full time

GENERAL SUMMARY:

The Care Management RN manages defined populations by using a collaborative process of assessment, planning, implementation, and evaluation, to engage, educate, and promote/influence beneficiary decisions related to achieving and maintaining optimal health status in the Outpatient setting. The Care Management RN uses a combination of proactive telephone calls, hospital, MD office, and home visits to beneficiaries who are enrolled in Meritage’s care management programs. This position is responsible for developing and maintaining ongoing supportive relationships with all members of the Care Management Team and beneficiaries.

PRINCIPAL ACCOUNTABILITIES:
• Reaches out to patients identified as appropriate to provide information and education in order to deepen their understanding of their medical condition and to guide the patient in self-management of medical conditions.
• Emphasizes the value of health education and behavior modification.
• Participates in all aspects of the Care Transitions Program.
• Actively participates in the Care Team to improve/maintain positive healthcare outcomes and care transitions.
• Works in collaboration with the individual patient and his/her attending physician.
• Supports the Primary Care Physicians and their office staff.
• Applies the standard elements of assessment, planning, implementation, coordination, monitoring, and evaluation and will use state-of-art information tools.
• Is highly organized, effective at managing her/his time, and is skilled in the use of computers and multiple software systems.
• Remains objective in relationships with patients, families, and physicians and promotes a team approach by encouraging communication among all members of the care team.
• Coordinates care among multiple treating physicians including specialists, primary care, hospitalists, and behavioral health care, as necessary.
• Consistently demonstrate behaviors, conduct and communications that support Meritage’s Practices and Values of Accountability, Diversity, Integrity and Respect for others, and will seek to influence these behaviors in others.
• Continuously endeavors to “raise the bar” of performance and teamwork through a focus on
Updated 10/2022
Innovation, Collaboration, Equality and Compassion. • Performs other clinical and related administrative duties as assigned to support the
organization’s operational needs.

Job Requirements

REQUIREMENTS & QUALIFICATIONS:
• Current California RN License with no restrictions; and a minimum of 2 years clinical experience (inpatient or outpatient); previous case/care management experience is preferred.
• Bachelor’s degree in nursing preferred.
• Coleman model trained is a plus.
• Accountable Care Organization (ACO) and Direct Contracting Entity (DCE) experience desired.
• Familiarity with data collection and methods of analyzing and reporting data, metrics, and related information pertaining to clinical health programs.
• Knowledge of care management regulations that fall under CMS, NCQA, DMHC and other applicable state and accreditation standards.
• Demonstration of sound clinical judgment and critical thinking in accordance with the California Nurse Practice Act.
• Professional written and verbal communication skills.
• Ability to function effectively in a team with patients, families, physicians, MD office, and other Meritage departments and staff.
• Treats others in a respectful, kind, and patient manner.
• Self-motivated, able to ask for assistance, and adapts easily to change.
• Has a strong sense of accountability for work performed and in meeting deadlines.
• Knowledgeable about the available health care and community resources for the populations managed.
• Understanding of family dynamics and the influence of cultural and spiritual values in health care.
• Current valid driver’s license and reliable transportation with the required level of automobile liability insurance coverage.

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Job Description

Location: California

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.

PRINCIPAL 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.
• Consistently demonstrate behaviors, conduct and communications that support Meritage’s Practices and Values of Accountability, Diversity, Integrity and Respect for others, and will seek to influence these behaviors in others.
• Continuously endeavors to “raise the bar” of performance and teamwork through a focus on Innovation, Collaboration, Equality and Compassion.

Job Requirements

REQUIREMENTS & QUALIFICATIONS:
• Current California RN License with no restrictions.
• Completion of Diploma or Associate’s Degree in Nursing; Bachelor’s Degree in Nursing preferred.
• Minimum five years of clinical experience; two years of experience in Managed Care Organization, Health Plan Utilization Management, Commercial HMO or Medicare, preferred.
• 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, CA

Employment Status: Full time

Position Summary:

As a key member of the Network Relations Department, serves as the primary point of contact for all incoming calls and inquiries to the department. Provides administrative support to the Network Liaisons while they are out in the field visiting provider offices or are otherwise occupied with meetings and events.  Assists with coordinating quarterly physician and network-wide newsletters and ad hoc communications with the provider offices. Assists with the coordination of Network events and meetings.  Sets up and maintains network department databases, files and records.

Responsible for all aspects of the credentialing, re-credentialing and privileging processes for all medical providers in Meritage Medical Network.  Responsible for ensuring providers are credentialed, appointed, and privileged with contracted health plans, and National Committee for Quality Assurance (NCQA) requirements. Maintain up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of licenses and certifications.  Works to develop and maintain a streamlined, efficient and automated process for credentialing and re-credentialing. Works closely with other Meritage staff (e.g., Claims and Utilization Review department staff), to update provider agreements in the Meritage database (Quickcap).

Duties and Responsibilities:

• Maintains a sound and comprehensive understanding of the Network Relations department and staff in order to assist internal and external customers to the department with service and information requests.
• Maintains a solid understanding of the Meritage Medical Network organization, services and staff and how such services and personnel support network physicians and practices.
• Answers department telephones, responds to general inquiries, takes messages and refers calls/inquiries to the appropriate Network Liaison, and/or refers calls as necessary to other Meritage staff/departments.
• Assists with the development of physician and office staff information and education materials for distribution in the field, including the Network Quarterly newsletter, to physician practices.
• Assists with the preparation and coordination of network physician social events such as the annual mixer as well as Practice Manager social events.
• Assists with the coordination of Regional Operations Committees and Membership Committee meetings, including but not limited to developing and maintaining committee lists, developing and sending out invitations, save the date reminders, reserving meeting locations, meal coordination, developing and disseminating meeting agendas and materials, and maintaining associated records and databases.
• Responsible for all aspects of credentialing/re-credentialing providers, to include but not limited to verification of application/documents, mailing of requests for consideration, initial applications, approval, denial, termination letters, tracking license and certification expiration for providers, and accurately loading/maintaining provider information into the Credentialing database.
• Prepares credentialing files and monthly matrices for presentation to the Membership Committee; responsible for confirming the completeness of information and all documentation prior to presentation.
• Maintains all of the credentialing documentation up to health plan audit standards and coordinates with health plans for annual credentialing audits.
• Maintains knowledge of current health plan and network requirements for credentialing
• Develops, maintains and provides reports from the department database and prepares custom reports, data searches and/or data analysis in response to specific requests by internal and external customers.
• Audits health plan directories for current and accurate provider
• Drafts credentialing policies and procedures as directed by the Membership Committee and/or Director of the Provider Relations department.
• Maintains confidentiality of provider
• Consistently demonstrate behaviors, conduct and communications that support Meritage’s Practices and Values of Accountability, Diversity, Integrity and Respect for others, and will seek to influence these behaviors in others.
• Continuously endeavors to “raise the bar” of performance and teamwork through a focus on Innovation, Collaboration, Equality and Compassion.
• Performs other duties as assigned related to supporting the Network Relations Department and the overall Meritage organization.

Job Requirements

Minimum Requirements and Competencies:

• Bachelor’s degree in a healthcare, business or related field of study; or equivalent combination of education and experience.
• 1-3 years’ related work experience, with a minimum of 2 years of current credentialing work experience, preferably in a managed care setting.
• National Association Medical Staff Services (NAMSS), Certified Provider Credentialing Specialist (CPCS) preferred.
• Excellent customer services skills with a demonstrated genuine and friendly demeanor.
• Strong written and verbal communications skills.
• Detail orientation with the ability to organize and prioritize work and manage multiple priorities with mature judgement.
• Ability to multi-task and meet deadlines and agreed upon deliverables.

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Job Description

Location: Novato, CA

Employment Status: Full time

Position Summary:

The Claims Examiner is responsible for processing, examining, and adjudicating medical claims for payment or denial in a manner that maintains compliance within respect to Commercial, Medicare Advantage and Medi-Cal regulatory requirements while achieving claims service level objectives. This position is responsible for the accurate and timely processing of all claims upon first receipt.

Essential Job Functions:

• Reviews and or enters claims data into system while interpreting coding and understanding medical terminology in relation to diagnosis and procedures.
• Review, analyze, and resolve claims through the utilization of available resources for moderately complex claims.
• Examines claims to determine if further investigation is needed from Sr. Claim Examiner or other departments and routes claims appropriately through the system.
• Adjudication of claims to achieve quality and production standards applicable to this position.
• Maintain procedural accuracy of 97%, and financial accuracy of 97%.
• Ensure legal compliance by following company policies, procedures, guidelines, as well as federal insurance regulations.
• Respond timely to all Customer Service, Provider Relations type questions.
• Collaborate with and maintain open communication with all departments within Meritage Medical Network to ensure effective and efficient workflow and facilitate completion of tasks/goals.
• Consistently demonstrate behaviors, conduct and communications that support Meritage’s Practices and Values of Accountability, Diversity, Integrity and Respect for others, and seeks to influence these behaviors in others.
• Continuously endeavors to “raise the bar” of performance and teamwork through a focus on Innovation, Collaboration, Equality and Compassion.
• Models professional work standards and behaviors to maintain and strengthen a professional working atmosphere and strictest confidentiality within the department and with other Meritage internal and external customers and work partners.
• Is accountable for work performed by self, works to develop and maintain trusting working relationships with others, and seeks to continuously learn from errors and experiences, as well as new developments in job specific Call Center administration and operational areas.
• Adopts, incorporates, is mindful of, and otherwise supports Meritage’s overarching annual and longer-term strategic business goals and objectives while performing work duties, special projects and other duties as assigned within or outside of the Call Center.
• Performs other than normally assigned duties and projects, as directed, and required, within and outside of the Claims department to support Meritage’s overall business needs, goals, and objectives.

Job Requirements

Requirements & Qualifications:

• High School diploma (or General Education Diploma “GED”) required.
• Minimum of 2 years’ experience processing or billing primary and specialty provider claims.
• Knowledge of DMHC, DHCS and CMS regulations.
• Comprehensive knowledge of CPT and ICD-10 codes.
• Must have excellent problem-solving skills.
• Excellent interpersonal written and verbal communications skills.
• Strong attention to detail.
• Enjoys working as part of a team.
• Multi-task and keyboard while researching, following up, resolving, and documenting telephonic inquires.
• Microsoft Office Suite applications: Word, Excel, PowerPoint, Outlook, Teams, etc.
• Knowledge of claim benefit interpretation/benefit adjudication
• Must be proficient in problem solving and detecting trends.
• Excellent communication skills – meaning you can adapt to new and different situations, read the behavior of others, have difficult conversations with ease and defuse and resolve conflict.
• Must be able to read and interpret all types of authorization, medical claim forms and member benefit plans.
• Integrity to follow HIPAA guidelines on maintaining patient privacy.
• Ability to adapt and excel in a fast-paced work environment.

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Job Description

Location: Novato, CA

Employment Status: Full time

Position Summary:

The outpatient Care Management Nurse is the key contact with the patient and providers. They are responsible for providing comprehensive assessments and developing, coordinating, and implementing the plan of care with other team members on those patients assigned. Maintain extensive knowledge regarding the current standards of care and care management processes for Asthma, COPD, Diabetes, Heart Failure, and/or other program-specified condition(s). Involved in two main programs at Meritage: Care Transitions and Complex Care Management.

Principal Responsibilities:

Care Transitions Program

• Provide post-hospital discharge support to all Meritage members who qualify for Care Transitions (depending on health plan) – based on Coleman Model (30-day program).
• Patients will receive either telephonic or face-to-face care transitions support.
• Use criteria such as the LACE tool to identify high risk patients.
• Goals and objectives:
  • Reduce preventable readmissions.
  • Increase the number of patients that are seen by an MD within 7-10 days of discharge.
  • Provide medication reconciliation and assist in identifying and correcting medication discrepancies.
  • Provide teaching regarding disease process, medications, community resources.
  • Educate members on seeking the appropriate level of care.
  • Reduce utilization costs by evaluating users with high outpatient costs.
  • Refer patients as appropriate to behavioral health staff.
  • Create personalized care plan for patient.

Complex Care Management

• CCM services to those patients identified as high-risk and will be referred into the program.
• Patients referred into the program will receive telephonic support for up to 90 days, as well as a home visit from the RN Care Manager (RN CM).
• Identify patient-centered goals and create personalized Plan of Care.
• Work with patient to achieve goals of care.
• Educate patient regarding disease processes, medications, community resources.
• Provide medication reconciliation as appropriate.
• Assist members with seeking appropriate level of care.
• Provide referral to Behavioral Health Care Management if appropriate.
• Work with Utilization Review for authorizations/provider referrals as appropriate.
• Work with quality department to improve quality scores.
• Patients who receive a home visit will also receive three follow up phone calls to address any ongoing needs, questions, or concerns.
• RN CM may provide the following via telephone or home visit (if deemed clinically appropriate):
• Assessment of patient health status.
• Identify patient centered goals and create plan of care.
• Educate patient regarding disease processes; signs and symptoms, when to notify MD.
• Interdisciplinary collaboration with MDs, therapists, home health agencies, family, etc.
• Discussion of preventative health measures.
• Medication reconciliation/discrepancies.
• Teaching of disease process, signs, and symptoms to be concerned about and when to call the doctor.
• How to seek the appropriate level of care.
• Referral to community resources/caregivers, etc. as appropriate.
• Home safety evaluation/falls risk assessment.
• Review of life planning/advanced care directions.
• Review of hospital discharge instructions if indicated.
• Work with UM for proper authorizations/providers if indicated.
• Provide ongoing support for patient to achieve goals.
• CCM patients are brought into weekly rounds with medical director.
• Consistently demonstrate behaviors, conduct and communications that support Meritage’s Practices and Values of Accountability, Diversity, Integrity and Respect for others, and will seek to influence these behaviors in others.
• Continuously endeavors to “raise the bar” of performance and teamwork through a focus on Innovation, Collaboration, Equality and

SNF 3-day Waiver Program

• Participate in the 3-day waiver program.
  • Point-person for hospitals, Skilled Nursing Facilities, primary care provider.
  • Care transitions/CCM for fee for service Medicare/Medicare Advantage beneficiaries who qualify for the 3-day SNF waiver (see above for duties for each service).

Job Requirements

Qualifications, Requirements and Skills:

• RN with current, unrestricted license in the state of California.
• 2+ years’ experience in inpatient or outpatient nursing. Case Management experience highly preferred.
• Bachelor’s or Master’s degree in nursing preferred.
• Able to work with different healthcare settings: Inpatient vs. Outpatient.
• Knowledge of CM regulations that fall under CMS, NCQA, DMHC and other applicable state and accreditation standards.
• Demonstration of sound clinical judgment and critical thinking in accordance with the California Nurse Practice Act.
• Commitment to service excellence and patient satisfaction.
• Proficiency in office-based software applications, including Word, Excel, Outlook, Teams and working knowledge of other healthcare charting software required.
• Ability to develop and maintain effective working relationships with other teammates, patients, and the public.
• Ability to multi-task in a fast-paced clinical setting.
• Excellent verbal, written and interpersonal communication skills.
• Ability to collaborate and build strong client relationships across all levels of the organization including clinical staff, physicians, and administrative leadership to meet deliverables.
• Ability to obtain reliable transportation to-and-from patient homes/facilities, when applicable.
• Aptitude for coaching, training, and developing new teammates.

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Job Description

Location: Novato, CA

Employment Status: Full time

POSITION SUMMARY:

We are seeking a Director of Accounting, to be responsible for all end-to-end accounting and financial reporting processes relating to our Direct Contracting, California Commercial, MediCal, and Medicare Advantage managed care revenue and healthcare costs streams (currently around $425M annually and increasing).

Reporting to our Chief Financial Officer, the Director of Accounting will be responsible for designing and executing SOX-compliant processes, establishing monthly contract reporting cadences, developing robust accounting estimates relating to variable revenue elements, and collaborating with the managed care finance team on revenue projections.

PRIMARY DUTIES AND RESPONSIBLITIES:

• Designing and implementing SOX-compliant controls relating to the monthly revenue and healthcare costs process, including membership analysis, comparison of capitation amounts to contracts, month-end reconciliations, medical claims analysis and journal entry processes.
• Being the subject matter expert (SME) on the underlying contracts, influencing forward-looking revenue projections, negotiating contractual revenue risk and quality adjustments, and identifying areas of future revenue contract optimization.
• Documenting judgmental positions relating to the application of ASC 606 to the underlying revenue contracts and performing annual Premium Deficiency Reserve (PDR) assessments.
• Partnering with internal and external actuaries to determine reasonable estimation approaches for claims expenses incurred but not reported.
• Driving automation initiatives to enhance the pace and accuracy of data transfers relating to membership numbers, membership claims and pricing.
• Partnering effectively across the global accounting team and with FP&A and commercial team individuals involved in forecasts and contracting negotiations.
• Reviewing existing accounting policies, procedures, and operational strategies, implement improvements and establishes new ones as necessary.
• Assisting in coordinating with external auditors and preparing audit schedules and other necessary documents to support both Global (SEC) and local regulatory (DMHC) reporting requirements.
• Coordinating and supporting Senior Accountants’ daily tasks.
• Revenue Enhancement / Recoveries:
  • Stop-loss / reinsurance.
  • Ensure claims are filed with reinsurance carriers and claims reaching thresholds are received.
• Risk factors experience:
  • Audits of risk pool reports.
  • Ensures claims submitted to maximize risk adjusted factor (RAF) institutional portion risk pool revenue.
• Assist with special projects as assigned.
• Consistently demonstrate behaviors, conduct and communications that support Meritage’s Practices and Values of Accountability, Diversity, Integrity and Respect for others, and will seek to influence these behaviors in others.
• Continuously endeavors to “raise the bar” of performance and teamwork through a focus on Innovation, Collaboration, Equality and Compassion.

Job Requirements

MINIMUM REQUIREMENTS & QUALIFICATIONS:

• Bachelor’s Degree in Accounting or related field, Master’s Degree strongly preferred, with a minimum of 7 years of directly related increasingly responsible accounting experience and a minimum of 5 years’ management experience; or equivalent combination of education and experience.
• Knowledge and use of US GAAP and accounting skills, especially relating to ASC 606.
• CPA or CFA qualification.
• 5 years+ in a healthcare environment: e.g. management service organizations, independent physicians associations, medical groups, health plans.
• Familiarity with healthcare revenue contracts, healthcare accounting and medical claims estimates would be ideal but is not essential (knowledge of California DMHC regulatory requirements is a bonus).
• Experience with a combination of NetSuite, Ivalua, G Suite platform, and Excel and Power BI would be advantageous.
• Highly analytical with the ability to evaluate complex accounting and financial data with limited supervision.

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Job Description

Location: Greenbrae, CA

Employment Status: Full time

Duties & Responsibilities:

Front office clerical including, but not limited to:

• Handling outbound and inbound phone calls.
• Scanning and faxing reports and authorizations.
• Schedule appointments.
• Take messages for patients using electronic medical records.
• Greet and check in patients.
• Collect copayments.
• Address patient requests and inquires.
• Resolve patient concerns.
• Process insurance issues (i.e., verifications and authorizations) and assist patients in understanding insurance plans.
• Various assigned administrative tasks.

Job Requirements

Qualifications & Skills:

• At least one year of related front office medical assisting experience.
• High school diploma or General Education Degree (GED) required.
• Working knowledge of medical terminology.
• Computer proficiency; familiarity with electronic health records (EHR); Practice Fusion preferred.
• Comfortable and experienced working with Medicare patients.
• Understand medical conditions and experience with medical insurances.
• Demonstrated punctuality, reliability and professionalism.
• Demonstrated exceptional customer service skills.
• Experienced multi-tasker.
• Exceptional communication skills, written and verbal.

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Job Description

Location: Novato, CA

Employment Status: Full Time

This position supervises the Accounts Payable area including establishing and implementing policies, procedures, practices, reports, and overseeing staff activities pertaining to the payment of invoices and reimbursement of applicable expenses for Meritage Medical Network (Meritage) and Prima Medical Group (PMG) within established timeframes. Sets up, organizes, maintains, retains, and develops accounts payable ledgers, and files for service agreements and contracts, business associate agreements, compliance attestations, and related records for vendors, suppliers, business partners, independent contractors, consultants and other third parties with whom the organizations have financial arrangements for payment in exchange for goods and services. Ensures proper records retention and documentation to meet auditing standards and legal requirements. Position acts as a liaison between Meritage and PMG and their vendors and all managed entities related to Accounts Payable issues including managing project accounting for all business locations and providing support to senior management by developing reports and responding to inquiries. Duties require broad conceptual judgment, initiative, and ability to deal with complex A/P issues. Supervises staff and ensures work is properly distributed, processes are cross-trained, and deadlines are met. Serves as an A/P subject matter expert, trouble-shoots issue, and concerns, and works to ensure staff are trained in A/P work requirements and industry best practices. Continually assesses area workflow, practices and procedures for process improvement opportunities that support improved efficiency, productivity, regulatory and legal compliance, and employee and customer service and satisfaction.

Essential Job Responsibilities

• Develops and coordinates workflow and processes between Accounts Payable and other Meritage and PMG representatives.
• Oversees all vendor, consulting, and Independent Contractor agreements/contracts to ensure compliance with payment after services are rendered up to prescribed timeframes and capped fees.
• Obtains and maintains a thorough understanding of the data management and reporting capabilities and requirements of A/P systems and adheres to all applicable accounting standards (GAAP) and requirements.
• Performs general A/P system updates and maintenance (using departmental accounting software).
• Establishes, monitors, and regularly audits systems to ensure payments are accurate and there are no duplicative, late, miscoded or overpayments made to third parties.
• Responsible for processes and records pertaining to year end reporting including, but not limited to 1099’s.
• Supervises A/P staff to ensures roles are cross trained so that timelines are always met, provides training to new and existing staff as needed. Responsible for taking sick call from staff and coordinating requested time off to ensure there are appropriate staffing levels to accomplish work objectives.
• Responsible for hiring, firing, developing, assessing performance, disciplinary actions, and providing daily coaching and recognition to assigned staff; keeps Accounting leadership informed about related issues.
• Initially and on an ongoing periodic basis, spends time with each staff member to gain an understanding of their job duties, challenges, and to better identify and support process improvement initiatives.
• Develops and documents policies and procedures to strengthen department processes and internal controls
• Analyzes area work and develops new procedures to enhance workflow and improve efficiency while maintaining or enhancing accuracy
• Participates in month/quarter/year-end close processes and prepares accurate, timely and meaningful analytics and statements regarding A/P work, projects, and outcomes. financial statements in accordance with established schedules
• As needed, participates in budget processes and prepares A/P variance reports and analysis
• Demonstrates/models excellent internal/external customer service, maintains a professional work demeanor, and ensures strict confidentiality.
• Performs related work as required, special projects and other duties as assigned• Works with direct reports to establish annual work area goals and objectives and coaches on the progress to enhance professional development of staff.
• Actively participates and engages on the company’s Management Leadership Team (MLT) by partnering with other managers on cross-functional work efforts and projects, opening up lines of communication with other departments, providing periodic training as required, attending monthly and ad hoc MLT meetings and events, and serving as an in-house subject matter expert for Accounts Payable matters and questions.

Job Requirements

Education and Experience Requirements

• An Associates or Bachelor’s degree in Accounting or related field and a minimum of 5 years of increasingly responsible Accounts Payable work experience, including 3 years of supervisory experience and a working knowledge of performance improvement principles and practices. Or an equivalent combination of education and work experience.
• Proficiency with A/P and Accounting systems, databases, and records maintenance systems.
• Must have experience full-charge A/P in an ERP system (MS Dynamics Business Central preferred).
• Proficiency with Microsoft Office applications including Excel, Word, and PowerPoint.
• Excellent written, verbal, and listening communications skills.
• An accountable, respectful, and professional demeanor that engenders trust and supports a team approach to work.

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Job Description

Location: Novato, CA

Employment Status: Full Time

Position Summary

Prepares consolidated financial statements including balance sheets, income statements, and cash flow statements. Reviews and analyzes account balances, verifies accuracy, prepares reconciliations and other supporting schedules, investigates issues and makes recommendations for corrections. Develops and enhances accounting/finance applications and reports based on management needs for performance measurement. Provides guidance, assistance and back-up to other accounting and support staff as required/assigned, including revenue, accounts receivable/payable, payroll, and provider compensation.

Essential Job Responsibilities

• The Senior Accountant maintains financial records and ensures that financial transactions are properly recorded
• Ensures the accuracy of entries to ledger accounts and reconciles subsidiary ledger accounts to the general ledger
• Supports month-end and year-end close processes and prepares accurate, timely financial statements in accordance with established schedule.
• Performs regular general ledger updates and maintenance using Microsoft Dynamics 365 Business Central accounting software.
• Conducts monthly and quarterly account balance reconciliations to ensure accurate reporting.
• Analyzes financial statements for discrepancies and other issues that should be brought to Senior Management’s attention.
• Participates in budgeting processes and prepares budget variance reports and analysis.
• Assists with preparation for annual audits.
• Develops and documents policies and procedures to maintain and strengthen department processes and internal controls.
• Conducts other finance-related analysis and prepares reports to support management objectives.
• Assists with the training of department staff, cross-trains to provide back-up for other finance department processes.
• Adheres to required GAAP standards.

Job Requirements

Education, Experience and Qualifications

• Bachelor’s degree in accounting. CPA or CPA-ready is preferred or a combination of experience and education.
• Minimum 5 years of current professional hands-on accounting experience including 3-5 years in a health care organization, managed care environment preferred. Additional experience with accounts payable and payroll is a bonus.
• Ability to work at an advanced level with Excel and accounting applications (Microsoft Dynamics, NetSuite, Great Plains or similar).
• Ability to perform mathematical computations and compute ratios and percentages.
• Skill in defining problems, collecting data, interpreting financial material.
• Skill in preparing statistical and narrative accounting and auditing reports.
• Ability to communicate clearly and to maintain effective working relationships.

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