Member Relations Compliance Rep

Why Choose Jefferson Health Plans?

We are an award-winning, not-for-profit health maintenance organization offering Medicaid, Medicare, and Children's Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members. We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.

While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ.

Perks of JHP and why you will love it here:

• Competitive Compensation Packages, including 401(k) Savings Plan with Company Match and Profit Sharing 
• Flextime and Work-at-Home Options
• Benefits & Wellness Program including generous Time Off 
• Impact on the communities we service 

We are seeking a talented and enthusiastic Member Relations Compliance Representative to join our team!

General Description:

This position reports to the Manager, Member Relations. Responsibilities include but are not limited to the monitoring of operational compliance requirements. This role requires mastering and demonstrating skills and concepts within all lines of business supported by Member Relations (currently Medicaid, Medicare, CHIP PPO, ACA) in reference to enrollment, appeals and grievances, Complaint Tracking Module, claims, billing, marketing, etc. The specific goal of this position is to effectively monitor and oversee operational measures for both internal Member Relations teams and affiliated vendors. This position also includes the management of CMS, DHS and OOC communication and assisting with audit objectives. Individual must be able to operate independently.

As the Member Relations Compliance Representative, your daily duties may include: 

• Serve as a point of contact for all internal departments and vendor for CMS, DHS, and OOC communications including HPMS issued guidance, and other relevant regulatory and sub-regulatory guidance.
• Review of CMS, DHS, OOC and NCQA guidance and how it applies to Member Relations and related first tier-downstream entities.
• Development of related processes and policies.
• Monitoring and documentation of operational compliance components.
• Effectively communicate with various internal management teams to ensure compliance with contractual/regulatory requirements.
• Act as a representative of Jefferson Health  Plans at internal and external meetings/workgroups, etc., as required or requested.
• Educate staff on compliance updates and how it applies to day to day operations for areas of responsibility.
• Assist with data collection and organization for Medicare, CHIP, NCQA and Medicaid audits, internal - external.  
• Maintain records to demonstrate timely completion of all internal requests.
• Assist management in reviewing, clarifying and disseminating CMS, DHS, OOC and NCQA guidance to appropriate Jefferson Health  Plans Member Relations staff and associated vendors.
• Report on trends and issues that impact the Member Relations Department staff.
• Participate in appropriate staff meetings.
• Responsible for the documentation and creation of operating procedures.
• Identify Training gaps/needs.
• Provide recommendations and feedback.
• Call listening to monitor for compliance and standard process.
• Act as an interdepartmental liaison.
• Coordinate cross-functional and interdepartmental initiatives.
• Facilitate training sessions and vendor oversight meetings.
• Mock audit activity as needed.
• Test calls- including the monitoring/documentation of quality results.
• Monitoring of call center performance. 
• Track performance outcomes and improvement activities. 

Qualifications

• Bachelor's degree preferred or equivalent work experience.   

Skills, We Value: 

• 2-3 years of Medicare and Medicaid operational experience.
• Preferred demonstrated experience across multiple Medicare, Medicaid, OOC and NCQA disciplines i.e. CTM, call center, grievances, and monitoring.
• Excellent written and verbal communication skills. 
• Ability to manage multiple tasks and adhere to deadlines.
• Bilingual a plus, but not necessary.
• Ability to work independent of direct supervision, but also must be able to meet and exceed deadlines for close turnaround timeframes. 
• Proficiency in Departmental Information Systems including DPW, Member Health Information System and Pharmacy Systems.
• Must possess ability to provide continual updates to management on all issues, bringing those with potential impact to the attention of management immediately.
• Ability to maintain open, amicable communication with government entities, and Health Partners management, in an effort to ensure development of a "partnership" relationship.