Accounting

Financial Analyst (Full Time, exempt)

Description:

Responsible for providing comprehensive financial and claims data analysis, hospital cost modeling and pricing, and special projects. Demonstrated competency to record, adjust, research and analyze revenue & expense transactions, claims payment, adjustments, utilization, patient population and other health related cost. Ability to create financial and statistical reports; prepare financial data, management reports, and settlement reports. Can multi-task with limited timelines.

Qualification:

Minimum 4 yrs experience in data analysis in healthcare with experience calculating cost. BS degree in Accounting, Finance, Math, or Computer Science with strong math skills. Knowledge of Title 22, 10 and 28 preferred, as well as Medi-Cal billing guidelines. Must be detail oriented and have good organizational and problem solving skills; strong communication skills and able to interact with internal/external staff. Strong computer skills including Excel and Access, along with database, modeling, and word processing experience.

Community Outreach & Business Enrollment

Business Enrollment Specialist (non-exempt)

Description:

Advocate for the health plan and assists prospects in obtaining and maintaining Plan membership in appropriate programs. Implement strategic marketing efforts with partners to target eligible population and compel prospects to choose the health plan. Ensures proper completion of program applications and utilizes all standard tracking processes to follow enrollee progress from application submission through enrollment.

Qualification:

Minimum 1 yr experience marketing public health care programs and customer service experience in a fast pace business environment, or a combination/equivalent of the two; 1 yr college or prior enrollment assistance experience a plus. Current Healthy Families Application Assistance and Medi-Cal Marketing Certification preferred; knowledge of the application process for other public programs and Public Charge concerns; knowledge of SPE (Single Point of Entry), POS (Point of Service) and AEVS (Automated Eligibility Verification System) preferred. Strong marketing orientation, oral/written communication skills, and organizational/time management skills. Bilingual in English & Spanish. Must be proficient in MS Word and Excel; knowledge of MHC (CSIM) a plus. Must be flexible to attend evening and weekend enrollment events; physically able to do extensive sitting, walking and climbing of stairs; and must be able to travel locally, possess a current valid California Driver's License, and proof of auto insurance coverage.

Healthcare Informatics

Senior Data Analyst (exempt)

Description:

Provides analytical, research, and technical database management support for Utilization Management, business-oriented analyses and program applications for Care1st Health Plan operations. Serves as the principle analytic and database management position focused for Utilization Management programs to produce high level of analytic reports and data flow projects on a regular and ad-hoc basis that assist various Care1st business units in improving patient care, assisting with cost control, revenue maximization, care coordination, efficiency, quality, compliance, and other projects.

Qualification:

Bachelor's degree in health, human sciences, statistical sciences, or computer sciences. At least 2 years experience working with population-based data and reporting, preferably in a managed care setting involving Medicare and Medicaid programs. At least 1 year experience working with clinical data, or 2 years of related working in computer data collections and analysis programming/system analysis. Proficient in collecting, managing, assuring data quality, and reporting all relevant data.

Medicare Operations

Medicare Operations Coordinator (Full Time, exempt)

Description:

Under the supervision of the VP of Pharmacy & Medicare Operations but in accordance with established policies and procedures coordinates activities related to the operation of the Care1st Medicare product line. This position has access to and regularly works with information that is proprietary, strategic and of critical nature. This position has significant amount of daily exposure to the organization and to outside parties.

Qualification:

Candidate must have knowledge of Medicare Advantage guidelines and regulations (MA and Part D); experience in accessing and navigating the Health Plan Management System (CMS HPMS); excellent knowledge of Medicare Marketing Material Guidelines as well as required Marketing Materials; experience submitting data to CMS to comply with MA and Part D Reporting Requirements; experience preparing and submitting Medicare Advantage Applications, including Plan Benefit Package (PBP) and Bid Pricing Tool (BPT) submissions; excellent communication skills; ability to interact with colleagues and external customers tactfully and courteously over the phone and in person; must be able to multi-task and work in a fast pace environment; excellent organizational skills and ability to prioritize tasks appropriately; must have working knowledge of MS Word, PowerPoint, Access and Excel and ability to type 45 wpm.

Member Services

Member Services Representative (Full Time, non-exempt)

Description:

Duties to include but not limited to delivering high quality customer service to Plan members, providers and Plan personnel in an efficient, effective and timely manner.

Qualification:

Excellent written/oral communication and customer service skills; inbound/outbound call center experience; prior HMO or other managed care experience of 2 yrs and PC skills preferred. Good decision making and problem-solving skills. Bilingual English/Spanish or English/Korean.

Pharmacy

Pharmacy Technician (Full Time, non-exempt)

Description:

Duties include, but not limited to, participating in the Care1st Prior Authorization and Care1st Clinical Programs, and helping medical and pharmacy providers with formulary and claims processing questions.

Qualification:

California Licensed Pharmacy Technician. Possess good verbal and written communication skills. Proficient in analytical applications (Microsoft Word, Excel and Access). Experience in retail pharmacy and/or managed care required; PBM exposure preferred.

Provider Network Operations

Analyst, Provider Network Operations (Full Time, exempt)

Description:

Responsible for the management of data and development of analyses in regards to the Care1st provider network. Specific tasks include the creation and management of department performance metrics, provider network adequacy reporting and maintenance and development of department tracking and reporting databases. Closely interacts with Managed Care Operations, Medical Management, Finance, Information Technology and other functional areas to gather data, interpret results and present findings and recommendations to senior management. Establishes policies and procedures for consistent management of data and reporting throughout the department.

Qualification:

BS degree with data management experience. Proficient in MS Office and Access database.


Provider Contracts Associate (Full Time, non-exempt)

Description:

Responsible for documenting and maintaining the content review and approval process for PCPs, Specialists, Ancillary Providers and Hospitals. This position will also be responsible for the quality oversight of Care1st provider contract files.

Qualification:

Bachelors degree preferred. Knowledge of managed care principles. Ability to express ideas clearly in both written and oral communications. Effectively understand and communicate contract interpretations. Proficiency with Microsoft applications, Word, Excel and Access.

Quality Management

QI Outreach Coordinator – San Diego (Full Time, non-exempt)

Description:

Provides clinical support, administrative assistance, and coordination as a member of the QI team. The primary responsibilities range from extensive traveling to physician office sites, assisting QI Outreach nurse, assisting the physician/physician office staff, medical record review, performing physician/physician's office staff education, data extraction, maintaining data systems, administrative assistance duties as it relates to HEDIS, Medicare HCC Risk Adjustment, Risk Assessment and other intervention programs initiated through the Quality Improvement Department.

Qualification:

High school diploma required. 1 to 3 yrs of medical or managed care experience. 1 to 3 yrs of administrative assistance, customer /client service experience preferred. Knowledge of databases, software programs and medical terminology preferred.

Management Informaion Systems

MIS Application Specialist (Full Time, Exempt)

Description:

Provides documentation, development, implementation and training support for specialized healthcare computer applications. Supports the McKesson CCMS product, assists the application owner, deploys the application to multiple departments, documents and expands functionality where required and develops training programs to maximize the use of this application.

Qualification:

Experience in basic application support and troubleshooting. Familiarity with the application environments, Microsoft server, network, SQL and desktop. Basic knowledge of SQL and database operation. Experience in gathering, documenting and validating user requirements development. Experience with basic administration tasks including Microsoft access control, SQL access control and other commensurate administrative systems. Experience in supporting end users, user training and documentation skills for both operation processes and application flow. Must have a 4 yr degree in computer science or related field, or commensurate work experience. Healthcare and/or healthcare insurance experience a plus.

Utilization Management

UM Case Management Nurse – Santa Clara (Full Time, Exempt)

Description:

Assists patients through the outpatient continuum of care in collaboration with the patient's primary care physician and employing contracted ancillary service providers and community resources. Optimizes member care in the ambulatory care setting to prevent/decrease emergency room visits and hospital admissions. Responsible for working closely with the member regarding their identified condition(s) and provides appropriate education directed toward member self-management. Frequency of member contact/communication is determined by the acuity and needs for each member.

Qualification:

Active California registered or vocational nurse license; minimum 2 yrs experience with acute inpatient or outpatient nursing; and minimum 2 yrs experience working in managed care and utilization/case management. Experience in home health preferred. Knowledge of Medicare, Medi-Cal, DHS, MRMIB, DMHC, and NCQA regulations. Computer proficiency with MS Office suite with ability to enter/extract computer data. Excellent oral and written communication skills. Bilingual English/Vietnamese.