Job DescriptionJob DescriptionPosition Summary: The Health Professional 3/MCI its responsible for providing intensive follow-up to members exhibiting behavior or an environment that may predispose them to incompliance with medical treatment thus resulting in increased hospitalizations, costly treatments and/or worsening of their mental health status. Intensive follow-up may consist of telephonic follow-ups, home visits, integration and coordination care with community agencies and coordination depending on the necessity. Essential Functions: 1. Conducts health risk assessment and identifies barriers that could affect or interfere with treatment effectiveness or adherence2. Communicates with providers in the community regarding the consumer’s treatment needs and develops appropriate care plans for specialized needs of members3. Follow-up by telephonic or/and community outreach and crisis intervention if necessary.4. Provides chronic care management, empowerment, motivational interviewing, services coordination and other clinically based activities as assigned, based upon member’s severity of condition. 5. Educates the patient about their disease state as well as other health issues relating to their plan care. 6. Collaborates with other professionals to obtain better treatment results and overall care7. Investigates, reviews and maintains data related to treatment, care and/or related services8. Establish case discussions with Medical Consultant and/or Medical Director9. Will represent the company in Court for cases under follow-up and prepare reports if necessary. 10. Documents all activities per APS policies and procedures.11. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable. 12. And all other duties assigned by the manager and/or supervisor.Education: · Bachelor’s Degree in a Behavioral Health field; Master’s Degree preferred. · Current, unrestricted license to practice preferred.Experience: · Minimum 2 years of experience in a Clinical, Behavioral or Managed Care field preferred.
Knowledge: · Strong knowledge in behavior principles, chronic illnesses and disease management. · Strong telephonic assessment and customer service skills.· Knowledge in community based resources.· Knowledge in clinical assessment and crisis intervention.· Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
Job DescriptionJob Description Position Summary: The Health Professional 3/MCI its responsible for providing intensive follow-up to members exhibiting behavior or an environment that may predispose them to incompliance with medical treatment thus resulting in increased hospitalizations, costly treatments and/or worsening of their mental health status. Intensive follow-up may consist of telephonic follow-ups, home visits, integration and coordination care with community agencies and coordination depending on the necessity. Essential Functions: 1. Conducts health risk assessment and identifies barriers that could affect or interfere with treatment effectiveness or adherence2. Communicates with providers in the community regarding the consumer’s treatment needs and develops appropriate care plans for specialized needs of members3. Follow-up by telephonic or/and community outreach and crisis intervention if necessary.4. Provides chronic care management, empowerment, motivational interviewing, services coordination and other clinically based activities as assigned, based upon member’s severity of condition. 5. Educates the patient about their disease state as well as other health issues relating to their plan care. 6. Collaborates with other professionals to obtain better treatment results and overall care7. Investigates, reviews and maintains data related to treatment, care and/or related services8. Establish case discussions with Medical Consultant and/or Medical Director9. Will represent the company in Court for cases under follow-up and prepare reports if necessary. 10. Documents all activities per APS policies and procedures.11. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable. 12. And all other duties assigned by the manager and/or supervisor.Education: · Bachelor’s Degree in a Behavioral Health field; Master’s Degree preferred. · Current, unrestricted license to practice preferred.Experience: · Minimum 2 years of experience in a Clinical, Behavioral or Managed Care field preferred.Knowledge: · Strong knowledge in behavior principles, chronic illnesses and disease management. · Strong telephonic assessment and customer service skills.· Knowledge in community based resources.· Knowledge in clinical assessment and crisis intervention.· Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
Job DescriptionJob Description Position Summary: The Health Professional 3/MCI its responsible for providing intensive follow-up to members exhibiting behavior or an environment that may predispose them to incompliance with medical treatment thus resulting in increased hospitalizations, costly treatments and/or worsening of their mental health status. Intensive follow-up may consist of telephonic follow-ups, home visits, integration and coordination care with community agencies and coordination depending on the necessity. Essential Functions: 1. Conducts health risk assessment and identifies barriers that could affect or interfere with treatment effectiveness or adherence2. Communicates with providers in the community regarding the consumer’s treatment needs and develops appropriate care plans for specialized needs of members3. Follow-up by telephonic or/and community outreach and crisis intervention if necessary.4. Provides chronic care management, empowerment, motivational interviewing, services coordination and other clinically based activities as assigned, based upon member’s severity of condition. 5. Educates the patient about their disease state as well as other health issues relating to their plan care. 6. Collaborates with other professionals to obtain better treatment results and overall care7. Investigates, reviews and maintains data related to treatment, care and/or related services8. Establish case discussions with Medical Consultant and/or Medical Director9. Will represent the company in Court for cases under follow-up and prepare reports if necessary. 10. Documents all activities per APS policies and procedures.11. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable. 12. And all other duties assigned by the manager and/or supervisor.Education: · Bachelor’s Degree in a Behavioral Health field; Master’s Degree preferred. · Current, unrestricted license to practice preferred.Experience: · Minimum 2 years of experience in a Clinical, Behavioral or Managed Care field preferred.Knowledge: · Strong knowledge in behavior principles, chronic illnesses and disease management. · Strong telephonic assessment and customer service skills.· Knowledge in community based resources.· Knowledge in clinical assessment and crisis intervention.· Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
Job DescriptionJob Description Position Summary: The Client Services Coordinator 2 provides customer service in a call center environment. This key individual communicates with a wide variety of internal and external contacts including staff, members, providers, facilities, as well as clinical and operational staff. The Client Services Coordinator assesses the needs of internal and external clients in a timely and efficient manner, thus resulting in optimum operational performance. Essential Functions: 1. Provides quality care for members by assessing customer experience and care through services provided. 2. Recognizes customer needs to assist in issue resolution and effective outcomes. 3. Maintains a record of customer’s calls utilizing various documentation operating systems. 4. Answers calls and completes post-call work in a timely manner.5. Conducts investigations to resolve customer inquiries while adjusting complaints of services rendered. 6. Performs data entry and maintains a high level of customer satisfaction with timely problem resolution.7. Keeps track of regulatory and compliance metrics that could affect procedures or services rendered. 8. Elaborates customer communication materials and general service assessments. 9. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable.10. In addition, all other duties assigned by the manager and/or supervisor. Education:· High School Diploma required. · Bachelor’s degree preferredExperience: · Minimum 2 years of experience in a customer service position. Knowledge: · Knowledge in medical terminology preferred.· Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
Job DescriptionJob DescriptionPosition Summary: The Health Professional 3/MCI its responsible for providing intensive follow-up to members exhibiting behavior or an environment that may predispose them to incompliance with medical treatment thus resulting in increased hospitalizations, costly treatments and/or worsening of their mental health status. Intensive follow-up may consist of telephonic follow-ups, home visits, integration and coordination care with community agencies and coordination depending on the necessity. Essential Functions: 1. Conducts health risk assessment and identifies barriers that could affect or interfere with treatment effectiveness or adherence2. Communicates with providers in the community regarding the consumer’s treatment needs and develops appropriate care plans for specialized needs of members3. Follow-up by telephonic or/and community outreach and crisis intervention if necessary.4. Provides chronic care management, empowerment, motivational interviewing, services coordination and other clinically based activities as assigned, based upon member’s severity of condition. 5. Educates the patient about their disease state as well as other health issues relating to their plan care. 6. Collaborates with other professionals to obtain better treatment results and overall care7. Investigates, reviews and maintains data related to treatment, care and/or related services8. Establish case discussions with Medical Consultant and/or Medical Director9. Will represent the company in Court for cases under follow-up and prepare reports if necessary. 10. Documents all activities per APS policies and procedures.11. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable. 12. And all other duties assigned by the manager and/or supervisor.Education: · Bachelor’s Degree in a Behavioral Health field; Master’s Degree preferred. · Current, unrestricted license to practice preferred.Experience: · Minimum 2 years of experience in a Clinical, Behavioral or Managed Care field preferred.
Knowledge: · Strong knowledge in behavior principles, chronic illnesses and disease management. · Strong telephonic assessment and customer service skills.· Knowledge in community based resources.· Knowledge in clinical assessment and crisis intervention.· Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
Job DescriptionJob Description Position Summary: The Client Services Coordinator 2 / G&A provides outstanding customer service. This key individual communicates with a wide variety of external contacts including members, providers, facilities, as well as clinical and operational staff. The Client Services Coordinator assesses the needs of internal and external clients in a timely and efficient manner, thus resulting in optimum operational performance. The Client Services Coordinator 2 is fully dedicated to duties of the Quality Department. This employee is not responsible for conducting any UM review activities that require interpretation of clinical information.
Essential Functions: 1. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable.. 2. Recognizes customer needs to assist in a complaint, grievances, or appeals.. 3. Receives, prepares, and manages a complaint, grievances, or appeal file. 4. Maintains a record of grievances and appeals utilizing various documentation operating systems.5. Conducts investigations to resolve complaints, grievances, and appeals. 6. Maintains database by entering information related to the department.7. Sends letters to beneficiaries and facilities when the regulations are applicable. 8. Monitors and complies with the period to send notifications to the beneficiaries and the facility. 9. Use of clinical data is limited to: Performance of review of service request for completeness of information; Collection and transfer of non-clinical data; and Acquisition of structured clinical data; and Activities that do not require evaluation or interpretation of clinical information.10. In addition, all other duties assigned by the manager and/or supervisor. Education: · Bachelor’s degree requiredExperience: · Minimum 2 years of experience in a customer service position.Knowledge: · Knowledge in medical terminology preferred.· Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
Job DescriptionJob DescriptionPosition Summary: The Administrative Assistant provides support for the Clinic Administrator duties, which may include but are not limited to patient admission, completion of patient demographic sheets, preparation of claim forms, keeping record of patient appointments and visits, among others. This key individual will collaborate with the Clinical Administrator for the effective completion of claims, inventory preparations and ordering necessary supplies.Essential Functions: 1. Responds calls and arranges proper solutions. 2. Receives patients for admission and completes initial demographic forms. Completes patient information and billing forms such as: health plan information, authorization for disclosure, payment options, guides regarding treatment, etc. 3. Assists in initial patient orientation about services and offerings as needed. Collaborates in the preparation of certifications solicited by patients and plans for patient signature is necessary.4. Collaborates in the preparation of deductibles and/or co-payments as established by the patients’ health plan. Maintains and monitors the accuracy of patient admission registries within the system. 5. Completes reconciliation of deductibles and provides timely reports for the Billing Department. 6. Organizes and archives records, as well as ensures that patient records are up to date. 7. Assembles and monitors a proper stock of materials and forms for clinic daily utilization. 8. Collaborates with the EMR audit process.9. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable. 10. In addition, all other duties assigned by the manager and/or supervisor. Education:· Associate degree in secretarial science preferred · High School degree Experience: · Minimum 2 years of experience in administrative assistant position or similar. Knowledge: · Knowledge in medical billing, preferably in healthcare setting.· Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
Job DescriptionJob Description Position Summary: The Administrative Assistant provides support for the Clinic Administrator duties, which may include but are not limited to patient admission, completion of patient demographic sheets, preparation of claim forms, keeping record of
patient appointments and visits, among others. This key individual will collaborate with the Clinical Administrator for the effective completion of claims, inventory preparations and ordering necessary supplies. Essential Functions: 1. Responds calls and arranges proper solutions. 2. Receives patients for admission and completes initial demographic forms. Completes patient information and billing forms such as: health plan information, authorization for disclosure, payment options, guides regarding treatment, etc. 3. Assists in initial patient orientation about services and offerings as needed. Collaborates in the preparation of certifications solicited by patients and plans for patient signature is necessary. 4. Collaborates in the preparation of deductibles and/or co-payments as established by the patients’ health plan. Maintains and monitors the accuracy of patient admission registries within the system. 5. Completes reconciliation of deductibles and provides timely reports for the Billing Department. 6. Organizes and archives records, as well as ensures that patient records are up to date. 7. Assembles and monitors a proper stock of materials and forms for clinic daily utilization. 8. Collaborates with the EMR audit process. 9. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable. 10. In addition, all other duties assigned by the manager and/or supervisor. Education: · Associate degree in secretarial science preferred · High School degree Experience: · Minimum 2 years of experience in administrative assistant position or similar. Knowledge: · Knowledge in medical billing, preferably in healthcare setting. · Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
Job DescriptionJob DescriptionPosition Summary:The Quality Coordinator 2 assist the QI Supervisor and in the development, coordination, and implementation of the local quality improvement program, ensuring that performance objectives and standards meet and exceed quality expectations. This key individual assist with complaints, appeals, adverse incidents, training scheduling and reporting processes. The Quality Coordinator is fully dedicated to duties of the Quality Department.Essential Functions: Coordinates, organizes, analyses, and provides follow up for the TRR, as well as prepare corrective action plans. Assist QI Supervisor in the development, coordination and implementation of quality indicators tools, such as silent monitoring, internal audits, and quality committee meetings, among others. Compiles case information for the investigation and resolution of Adverse Events and Quality of Care.Collect data, maintain databases, and assist in identifying opportunities for improvement. Development of monthly, quarterly and annual reports. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable. In addition, all other duties assigned by the manager and/or supervisor. Education: Master’s Degree in a Behavioral Health field or bachelor’s degree in Nursing. Current, unrestricted clinical license(s) to practice in Puerto Rico territory. Experience: Minimum 2 years of experience in Managed Care, Behavioral Health Management and or Healthcare Quality Improvement preferred.Knowledge: Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
Job DescriptionJob DescriptionResumen del puesto:El Coordinador de Calidad 2 asiste al Supervisor de Calidad y en el desarrollo, coordinación e implementación del programa local de mejora de la calidad, garantizando que los objetivos y estándares de rendimiento cumplan y superen las expectativas de calidad. Esta persona clave colabora en los procesos de quejas, apelaciones, incidentes adversos, programación de la formación y elaboración de informes. El Coordinador de Calidad se dedica plenamente a las tareas del Departamento de Calidad.Funciones esenciales: Coordina, organiza, analiza y realiza el seguimiento de los TRR, así como la preparación de planes de acciones correctivas. Asistir al Supervisor de QI en el desarrollo, coordinación e implementación de herramientas de indicadores de calidad, tales como monitoreo silencioso, auditorías internas y reuniones del comité de calidad, entre otras. Recopila información de casos para la investigación y resolución de Eventos Adversos y Calidad Asistencial.Recopila datos, mantiene bases de datos y colabora en la identificación de oportunidades de mejora. Elaboración de informes mensuales, trimestrales y anuales. Cumple con todas las directrices establecidas por los Centros de Medicare y Medicaid (CMS) y las directrices establecidas por otras agencias reguladoras, en su caso. Además, todas las demás tareas asignadas por el gerente y/o el supervisor. Formación: Maestría en un campo de salud conductual o licenciatura en enfermería. Licencia(s) clínica(s) vigente(s) y sin restricciones para ejercer en el territorio de Puerto Rico. Experiencia: Mínimo 2 años de experiencia en Atención Gestionada, Gestión de Salud Mental y/o Mejora de la Calidad Sanitaria preferiblemente.Conocimientos: La experiencia informática personal debe incluir el trabajo con Microsoft Word, Excel, Power Point y Outlook a nivel intermedio como mínimo.
