Univera HealthСare

Job Description: Summary: Responsible for managing and providing divisional support to all Medical Records Unit (MRU) activities such as medical record requests, receipts, research and tracking through the medical record database. Research Facets, Plan Connexion processing system and control workflow to ensure intakes are handled timely by the appropriate area, including BlueCard and Local claims, to ensure performance metrics are met. Essential Accountabilities: Level I • Responsible for the quality assurance of all internal and external medical record requests and the determination of appropriate outgoing communication. • Review medical record receipts including unsolicited medical records for completeness and determine appropriate workflow. • Interface with and extract data from the Facets and/or Plan Connexion processing systems to prepare and complete medical record reports. • Process and maintain current and accurate Department of Labor medical record requests. •...

Job Description: Summary: The Manager of Credentialing Operations has direct responsibility for managing the internal operational credentialing activities for the Health Plan. The Manager oversees the end-to-end credentialing process for healthcare providers in compliance with regulatory, accreditation, and organizational standards. This role manages daily operations, leads credentialing staff, and ensures timely verification, enrollment, and maintenance of provider credentials. They are responsible for monitoring performance metrics, enforcing quality standards, and driving process improvements to increase efficiency and ensure accuracy in provider data systems. Essential Accountabilities: Accomplishes defined objectives and oversees all activities which relate to provider credentialing through effective planning, organization and utilization of personnel and equipment. Develops and implements department goals and corresponding action plans and monitors performance...

Job Description: Summary: Under the direction of the Assigned Management, upon successful completion of all phases of training, and in accordance with established HIPAA regulations the Enrollment Specialist performs enrollment core processing and servicing in accordance with the Health Plan Operation's enrollment regulations, Underwriting Guidelines and applicable government regulations. The focus of this role is to ensure prompt, accurate, and efficient servicing of all broker, member and group administrator inquiries for all product lines. Inquiries are received by the following but not limited to; telephone, email, written inquiries, lobby walk-in customers and through on-site visits with an employer group. The B version of this role will require the individual to be on the phone regularly. Essential Primary Responsibilities/Accountabilities: Level I: Responsible for Government Programs, Small, Mid, and Large Employer Group Subscriber Enrollment Operations. Responsible...

Job Description: Summary: The Finance Data Management Team is responsible for supporting the Finance division in several main capacities: management of the Workday Foundation Data Model and Workday Finance Business Processes, administration and development of Workday Accounting Center, administration of Workday Adaptive Planning, maintenance of Workday Finance configurations, and data management in support of reporting, integrations, audits and compliance. This role provides maintenance and administration of finance specific applications, data and business processes which provide support across the Finance division. A Financial Data Consultant collaborates cross-functionally throughout the organization to ensure the quality and timeliness of our financial transactions, reporting and analysis. Essential Accountabilities: Level I • Participates in administration and configuration across all finance technologies supported by the Finance Data Management team which include...

Job Description: Summary: The Business Systems Analyst is a critical role in the delivery of products for Lifetime Healthcare Companies. This position collaborates with stakeholders throughout the organization to understand business objectives and defines IT system requirements and specifications for the implementation of IT system solutions. The Business Systems Analyst will serve as the primary interface between the business and IT teams to gather, document and analyze all level of requirements with the emphasis on delivering functional and non-functional requirements to solution architects and IT teams. Business Systems Analyst, in collaboration, with their stakeholders sets scope for work items. Essential Accountabilities: All Levels: Collaborates with all stakeholders to elicit, analyze, specify, and gather business, stakeholder, and solution requirements. This will include assisting and/or contributing to the creation of documented requirements leveraging the...

Job Description: Summary: The FSA/HRA Plan Administrator responds to and resolves written, telephone, and personal inquiries from subscribers, groups, and providers concerning all departmental products, policies, and procedures in a professional and efficient manner. This position coordinates and monitors daily administrative activities regarding departmental products to ensure established standards and deadlines are met. Departmental Product Portfolio: Flexible Spending Accounts (FSA), Health Reimbursement Arrangements (HRA), Health Savings Accounts (HSA), Transit and Parking, Student Loan, Tuition Reimbursement and Wellness Benefits. Essential Accountabilities: Level I Responds to all inquiries from an internal and external perspective completely, accurately, and timely and in a professional and efficient manner. Supports customer service team in researching member inquiries. Researches claims and determines claim eligibility in accordance with IRS regulations....

Job Description: Summary: This position assists the Health Plan in establishing a presence in the community through home visits and community outreach bridging the gap between members and the Clinical Operations Department. Community Connections Representatives educate members about accessing community resources and assists with navigating resources available and provide assistance with addressing SDoH barriers and care gaps. This position educates and assists with the enrollment and recertification process for Marketplace Facilitated Enrollment (MFE): On and Off Marketplace health insurance products, including Child Health Plus (CHP), Medicaid Managed Care (MA/MMC), Essential Plan (EP) and the Individual Market - Qualified Health Plan (QHP). This position requires working occasional evenings and weekends for outreach and community events. Essential Accountabilities: Level I • Educates Medicaid, Medicare, and Commercial members on healthcare benefits, and community...

Job Description: Summary: The Manager of Data Platform Administration plans, directs, and evaluates the work of Data Platform Administration team in the planning, design, development and maintenance of new and existing applications and data systems. This position communicates with users to develop and maintain a firsthand knowledge of their plans, operations, problems, and opportunities. This position also champions the development, enforcement and refinement of standards for use, control, performance, updating and maintenance in conjunction with Data Platform Administration. This role reviews in-progress and completed work for completeness, quality, and adherence to standards. Essential Accountabilities: • Plans, directs and controls the activities of the analysis, design, development, and installation phases of the systems lifecycle. • Reviews service requests / projects and consults with executive sponsors, requesters, and/or user representatives to clarify intent,...

Job Description: Summary: The Business Coordinator supports the Government Programs (GP) line of business, organization, strategy, goals, and objectives to achieve required line of business (LOB) performance. This includes our SafetyNet (Medicaid, Child Health Plus-CHP), Essential Plan (EP) and HARP, along with Medicare, DUALS and Individual Market products. This position is engaged in all facets of the GP business and organization to support effective and efficient performance across the entire organization to deliver on goals and objectives. The GP Business Coordinator may often provide administrative support to the Government Programs leadership and full team as needed. Essential Accountabilities: Works directly with the Government Programs leadership regarding assigned GP business endeavors. Leads and coordinates special projects or tasks for leadership as necessary. Supports leadership in educating employees on company and business policies, practices, and procedures....

Job Description: Summary: This position supports the workflow of the Medical Services division. The Medical Services Coordination Specialist provides support for any of the programs of Behavioral Health, Quality Management, or Member Care Management. This position is responsible for adhering to certain regulatory requirements as well helping to support and connect members to appropriate internal Health Plan resources, Clinical Case Management team and external community support systems. Essential Accountabilities: Level I Review and prep clinical case for clinical staff. Assesses member's needs by applying Health Plan approved case management guidelines and assessment tools. Makes appropriate referrals to clinical programs. Collaborates with the clinical care team to support enrollees. Works with enrollee/caregiver/legal guardian to identify and achieve shared treatment goals. Manages a caseload productively and keeps appropriate documentation according to health...

Job Description: Summary: This role provides the vision, strategy, functionality, and technology solutions for creating and maintaining distributed platforms for both public and private cloud infrastructure-based solutions. This entails the design and use of flexible platforms that deliver features, functionality, and services compatible with industry-leading providers while allowing legacy systems to interact safely when required. This position requires the necessary skills to provide technology research, evaluation, development, and delivery in support of infrastructure deployment solution lifecycles. This position collaborates with the Information Technology teams to lead the organization toward the deployment of technologies that may include PaaS, SaaS, hosted, and on-premises solutions - which will allow for flexible, secure, on-demand cloud-like functionality and services while endeavoring to provide resiliency and achieve cost reduction, while maintaining a highly...

Job Description: Summary: Conducts case management program activities in accordance with departmental, corporate, NYS Department of Health (DOH), Centers for Medicaid & Medicare Services (CMS), Federal Employee Program (FEP) and National Committee for Quality Assurance (NCQA) accreditation standards, as appropriate to the member's case assignment. Uses a systematic approach to identify members meeting program criteria; assessing for opportunities to educate, support, coach, coordinate care and review treatment options, through collaboration with providers and community-based resources. Participates in a cross functional, multi-disciplinary team to identify and implement member-centric interventions to ensure optimal and cost-effective health outcomes. Collaborates with interdisciplinary care team to develop a comprehensive care plan to identify key strategic interventions to address member's needs, health goals and mitigate health care cost drivers. Essential...

Job Description: Summary: 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...

Job Description: Summary: The IT Platform Administrator acts as a liaison between the business and technical resources by ensuring the availability and successful operation of applications for users. This individual will demonstrate a high-level of responsibility and consistency by timely monitoring, responding, and troubleshooting of incidents, installing, upgrading, and maintaining application currency. This position will work to identify functionality to empower users through self-service and automation of relevant tasks. In addition to operating as application support, the IT Platform Administrator will perform periodic audits and maintain application compliance. The Administrator also frequently interacts with multiple departments to advocate for stakeholders' and platform best interests. Essential Accountabilities: Level I • Installs, configures, troubleshoots, patches, and maintains enterprise software platforms for applications to achieve reliable, highly available,...

Job Description: Summary: Conducts case management program activities in accordance with departmental, corporate, NYS Department of Health (DOH), Centers for Medicaid & Medicare Services (CMS), Federal Employee Program (FEP) and National Committee for Quality Assurance (NCQA) accreditation standards, as appropriate to the member's case assignment. Uses a systematic approach to identify members meeting program criteria; assessing for opportunities to educate, support, coach, coordinate care and review treatment options, through collaboration with providers and community-based resources. Participates in a cross functional, multi-disciplinary team to identify and implement member-centric interventions to ensure optimal and cost-effective health outcomes. Collaborates with interdisciplinary care team to develop a comprehensive care plan to identify key strategic interventions to address member's needs, health goals and mitigate health care cost drivers. Potential for...

Job Description: Summary: This role performs audits to ensure the organization is in compliance with federal, state and Association regulatory requirements (Centers for Medicare and Medicaid Services, Department of Health, Department of Financial Services, Department of Labor, Blue Cross Blue Shield Association, Federal Employee Plan, Office of Inspector General, Office of Medicaid Inspector General). The Administrator provides collaborative oversight and management of regulatory requirements to achieve optimal compliance performance to meet corporate goals. The incumbent will support risk mitigation by assessing regulatory compliance through various methods including auditing and monitoring, conducting root-cause analysis, identifying best practice opportunities, and making recommendations for process improvement or refinement activities. Essential Accountabilities: Level I • Researches, interprets, and communicates regulatory requirements to internal customers. Prepares...

Job Description: Summary: This position is the primary representative for Physician, Ancillary and Facility reimbursement analysis. The incumbent's analyses include but is not limited to, contracting strategies; calculation and testing of provider rates; implementation oversight for all regions and monitoring of provider reimbursement. In monitoring provider reimbursement, the position analyzes financial deals to assess the implications of rate structures and payment methodologies across markets, addresses variations in processes and fees among region and systems with the aim of developing common approaches, and monitors provider billing trends to ensure cost and quality management goals are met. Essential Accountabilities: Level I • Supports reimbursement strategy and analysis through various duties included running data queries for analysis and evaluation of current to proposed reimbursement rates. • Works with Provider Contracting on reimbursement implementations to...