Peak Health

Supervisor

• Supervise and coordinate daily operations and performance of a Medicare Member Services call center team
• Monitor call volumes, service levels, average speed of answer, abandonment rates, schedule adherence, quality, productivity, and other performance measures
• Ensure accurate member assistance regarding Medicare Advantage and D-SNP benefits, eligibility, enrollment, claims, authorizations, provider access, pharmacy coverage, grievances, and appeals
• Ensure compliance with CMS, Medicare, Medicaid, HIPAA, organizational, state, and federal requirements
• Monitor calls, CRM records, and member documentation for accuracy, completeness, professionalism, and compliance
• Identify training and continuing education needs; conduct coaching, counseling, recognition, corrective action, evaluations, reviews, and one-on-ones
• Communicate benefit, policy, regulatory, system, and operational changes through meetings, huddles, training, and email
• Oversee SharePoint and other systems for team resources and departmental documentation
• Coordinate resolution of member issues with Enrollment, Claims, Pharmacy, Provider Relations, Care Management, Appeals and Grievances, Compliance, Quality, and IT
• Handle escalated member, provider, authorized representative, and staff concerns and facilitate compliant resolutions
• Identify and refer complaints, grievances, appeals, coverage concerns, and compliance issues within required timeframes
• Work with the Manager or Director on departmental goals, performance standards, quality initiatives, and strategic priorities
• Maintain confidentiality of personally identifiable information and protected health information
• Review reports, quality findings, call-monitoring results, feedback, complaints, and compliance concerns to implement corrective or preventive actions
• Support onboarding, system access, training, mentoring, recruitment, interviewing, selection, and retention
• Manage schedules, attendance, timekeeping, PTO requests, break/lunch adherence, and staffing coverage
• Promote a professional, collaborative, inclusive, accountable, and member-focused work environment
• Work Saturday through Wednesday, 12:00 p.m. to 8:00 p.m.; schedule may change based on operational needs

Supervisor, Medicare Member Services

Nurse

• Collaborate with the Medical Director to decrease care variance and ensure timely discharges
• Refer members to other health plan resources to meet their care conditions
• Report to the Health Plan Manager of Utilization Management
• Serve as an integral and collaborative member of the health plan’s medical management team
• Assist with building and implementing care management review processes, including Prior Authorization, Predetermination, Concurrent Reviews, and Retrospective Reviews
• Implement care management reviews according to established criteria, clinical guidelines, and policies
• Ensure interventions are collaborative and focused on maximizing member healthcare outcomes
• Work with Medical Directors to improve the Peer-to-Peer Review process and member and Provider Network services
• Educate internal and external stakeholders and partners
• Collaborate with the medical management team to identify members who may benefit from coaching or case management interventions
• Understand collected data and work with team members to improve outcomes
• Participate in lifelong learning and continuous process improvement across Utilization Management

Utilization Review Nurse

Human Resources

• Partner with departmental leadership to develop, drive, and execute HR best-practice policies, programs, and training
• Provide value-added HR services to management and employees aligned with organizational objectives
• Attend department meetings to understand business activities
• Advise, coach, and provide HR solutions to functional and business leaders
• Support change management across business and service lines
• Drive talent assessment and career development initiatives
• Lead workforce planning through talent planning, including framework management, communication, reporting, gap analysis, action plans, monitoring, and executive sponsorship
• Deliver succession and replacement planning programs with leaders
• Maintain knowledge of succession planning best practices and update related policies and procedures
• Provide leadership training on succession planning tools, best practices, and processes
• Research and implement succession planning for critical and key positions
• Facilitate talent reviews and succession planning discussions
• Collaborate with CEOD on talent development programs
• Create reports and monitor succession plan effectiveness and HRIS data integrity
• Research and implement employee retention strategies and programs
• Conduct exit interviews, employee and management focus groups, and trend analysis
• Promote employee engagement and assist with engagement survey results
• Work with compensation, benefits, employee relations, CEOD, and disability management disciplines
• Assist with local audits

HR Business Partner

Representative

• Take inbound calls from Peak Health Medicare Advantage members and providers
• Answer questions ranging from general information to complex issues
• Research and resolve member issues and questions with management and peers
• Make outbound calls to members and providers for issue resolution or to gather information
• Verify member information and address general questions
• Resolve inquiries to provide an efficient and seamless member experience
• Conduct member outreach as required
• Handle Medicare claims processing and related inquiries
• Meet production and quality standards and maintain work queues
• Communicate effectively with internal and external staff
• Escalate issues to the appropriate level of supervision
• Ensure accuracy of information gathered and shared on members’ behalf
• Attend required training and demonstrate proficiency
• Maintain accurate documents, including timekeeping records
• Work an 8-hour shift between 7:30 a.m. and 8:00 p.m., Monday through Friday
• Work in a standard office environment using telephone, computer, copier, and fax equipment
• Travel requirement of 0%–25%

Medicare Member Services Representative

Full-stack Engineer

• Oversee end-to-end encounters data management, including ingestion, cleansing, transformation, and integration
• Develop and implement best practices for encounters data processing
• Collaborate with internal and external stakeholders to establish effective data integration processes
• Coordinate with IT teams and vendors to ensure accurate data exchange between systems and platforms
• Design and develop encounter data models aligned with industry standards and organizational requirements
• Optimize data models for efficient data retrieval and analysis
• Establish monitoring mechanisms for encounters data process performance and efficiency
• Identify optimization opportunities and implement measures to enhance system performance
• Provide technical expertise and guidance in encounters data management and analysis
• Set technical objectives and expectations and lead delivery of high-quality solutions
• Prioritize cross-functional demands, synthesize information, and generate meaningful conclusions
• Develop and implement team training programs
• Implement quality assurance processes and conduct regular audits for data accuracy and integrity
• Identify and resolve data-related issues with cross-functional teams
• Use advanced analytics to extract insights from encounter data
• Work with analytics teams to define data requirements and support analytical models and reports
• Ensure compliance with regulatory requirements, guidelines, and contractual obligations for CMS EDPS encounter submissions and response files

Encounters Technical Lead

Claims Specialist

• Analyze and process Medicare insurance claims in accordance with CMS guidelines
• Determine whether to return, deny, or pay claims according to organizational policies and procedures
• Screen, review, evaluate online entry, correct errors, and perform quality control for final adjudication of paper/electronic claims
• Ensure accuracy of data entered and maintain records
• Analyze claims to determine insurance carrier liability
• Resolve claim edits, review history records, and determine benefit eligibility for services
• Review payment levels and arrive at final payment determinations
• Interpret contract benefits and adjudicate claims according to Medicare claims processing guidelines
• Meet production and quality standards and maintain work queues
• Communicate effectively with internal and external colleagues
• Escalate issues to the next level of supervision as appropriate
• Attend required training and demonstrate proficiency
• Read and interpret explanations of benefits (EOBs)
• Mentor less experienced staff as assigned
• Maintain patient/member confidentiality under PHI and HIPAA guidelines
• Report to the Medicare Claims Supervisor

Supervisor, Medicare Member Services

Utilization Review Nurse

HR Business Partner

Medicare Member Services Representative

Encounters Technical Lead

Medicare Claims Processor