Description and Requirements
The Clinical Disenrollment Specialist will assess disenrollment requests from care teams to ensure adherence to regulatory requirements, and achievement of quality standards.
Duties/Responsibilities:
• Applies clinical and critical thinking skills in evaluating the content of disenrollment requests
• Communicates with the clinical teams regarding safety concerns and regulatory requirements on an ongoing basis
• Proficiently uses systems and applications such as TruCare, PEGA, MHS, ePACES and CMS.
• Validates content of disenrollment requests in reviewing of Uniform Assessment System (UAS) assessments, care plans, medical authorizations, and supporting documentation to ensure compliance with regulatory requirements and internal policies
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• Ensures disenrollments are processed within 24 hour time frame
• Communicates with internal teams and external facilities and vendors for safe and successful processing of disenrollments from the plan
• Maintains tracking tool to log disenrollment review results including areas of non-compliance and informing PCMs in what areas of improvement are needed for discussion with their managers as it pertains to disenrollment
• Address authorizations to reflect exit date from plan
• Outreaches and communicates with members and representatives as needed in reference to disenrollment status/requests
• Additional duties as assigned
Minimum Qualifications:
• RN, LCSW, LMSW, LMFT, LMHC, LPC, licensed psychologist (any state)
Preferred Qualifications:
• Critical thinking skills with a demonstrated ability to handle rapidly changing workflow situations
• Knowledge and experience with the current community health practices for the frail adult population and cognitive impaired seniors
• Proficiency in TruCare, ePACES, MHS and CMS
• Experience managing member information in a shared network environment using paperless database modules and archival systems
• Experience and knowledge of the relevant product line
• Relevant work experience preferably as a Care Manager
• Demonstrated ability to multi-task and effectively work in a fast-paced environment
• Proficient with simultaneously navigating the Internet and multi-tasking with multiple electronic documentation systems.
• Experience using Microsoft Excel with the ability to edit, search, sort/filter and other Microsoft and PHI systems
Hiring Range:
- Greater New York City Area (NY, NJ, CT residents): $81,099 - $116,480
- All Other Locations (within approved locations): $71,594 - $106,080
As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.
In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
The hiring range is defined as the lowest and highest salaries that Healthfirst in "good faith" would pay to a new hire, or for a job promotion, or transfer into this role.
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.