To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. 1. Build and maintain positive working relationships with staff, residents, community partners and governmental agencies; form and foster partnerships with safety net and community organizations, and with government agencies. 2. Act as liaison with comm

To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. Business Systems Analyst I Project and task management for small scale projects including facilitate stakeholder and project team meetings, track actionable items, send regular project communications to team members and stakeholders, and escalate identi

To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. Develop, implement and manage all UM processes for continuous and sustained compliance with all applicable state, federal and NCQA regulatory requirements, SCFHP policies and procedures and general business requirements for all lines of business. Develo

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Conduct, review and document comprehensive clinical and/or psychosocial assessments and on going follow up interventions to measure progress towards meeting goals as they relate to a member's physical, psychosocial, environmental, safety, developmental,

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Act as the primary point of contact and liaison for SCFHP members and providers contacting the plan regarding general inquiries, concerns or requests for information. Develop a general understanding of all member facing materials, communications and int

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Maintain a working knowledge of SCFHP's provider network structure and contracting relationships and apply to day to day management of the information contained in the core operating/claims system. Update and maintain SCFHP's core operating/claims syste

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Conduct clinical review to ensure effective and appropriate utilization of benefits and services for prospective, concurrent and retrospective appeals within regulatory turnaround requirements for all SCFHP lines of business. Apply appropriate clinical

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Thoroughly understand the various contract templates and be able to customize the appropriate template based on the specific situation. Using SCFHP templates, draft, negotiate, and process contracts, amendments, termination notices and Letters of Agreem

To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. Act as a back up to the Grievance and Appeals Intake Specialist during times of high volume work and/or staffing shortages to ensure appropriate intake of new and existing grievance and appeal cases, assessing the priority of each case and routing to th

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Maintain a working knowledge of SCFHP's provider network structure and contracting relationships and apply to day to day management of the information contained in the core operating/claims system. Update and maintain SCFHP's core operating/claims syste

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Responsible for revenue and cost reconciliation activities using capitation invoices, eligibility files, claims and expense data and other relevant reports. Design and prepare reports that analyze the financial outcome of programs and make recommendatio

To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. Implement strategies and initiatives on the HEDIS & MCAS work plan, including managing projects of varying degrees of complexity (i.e., administration of DHCS surveys, Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, multi channel

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Lead and facilitate medium to large scale quality and process improvement projects by providing direction for project framing, organization, business case analysis, implementation, and outcome/success measurement. In addition to Process Improvement proj

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Develop strategies, and provide direction, resources and support for department staff in coordinating NMT and NEMT transportation services to ensure members receive appropriate transportation services in a timely manner. Manage the team who work directl

To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. Ensure PHM initiatives meet all regulatory requirements for PHM. Plan, manage, and evaluate program initiatives to improve performance especially as it relates to key components of PHM (as compliant with all regulatory requirements). Collaborate and coo