SCAN

General

• Coordinate the work of a team of Member Services Representatives providing customer services to members and associated individuals and groups
• Focus on Medicare Advantage Part C and D Post-Service Appeals
• Ensure member inquiries are addressed and refer members to appropriate service providers
• Administer policies and procedures for verifying member identity, membership status, and entitlement to services
• Maintain current and accurate membership databases and records
• Suggest new service offerings or revisions to existing programs based on member feedback or coverage gaps
• May participate in member retention or renewal efforts
• Support SCAN’s Vision and Goals
• Perform other duties as assigned

Grievances and Appeals Coordinator

Financial Planning and Analysis

• Assist the manager in leading the department to ensure accurate system configuration, capitation payment processing, accruals, shared risk pool calculation, and claims expense recording.
• Interpret contractual agreements to ensure system accuracy and compliance.
• Manage databases and ensure provider payments are accurate.
• Ensure data integrity for audit and bid processes for all entities.
• Facilitate and lead intradepartmental meetings for audits, accruals, data analysis, annual CMS bids, capitation, and claims reserves.
• Oversee timely and accurate shared risk pool settlements and provide guidance on contract language.
• Liaise with Network Management, Shared Services, Claims, Legal, Actuary, Compliance, and Enrollment.
• Test, validate, monitor, and report on the capitation module; improve processes and support CMS guidelines and system upgrades.
• Maintain capitation and shared risk modules through configuration, analysis documentation, and system testing.
• Mentor team members and assist with escalated issues and tasks.
• Assure timely and accurate monthly provider capitation payments.
• Create system documentation, process flows, and desktop procedures.
• Evaluate contractual agreements related to payment methodologies for capitated and shared risk arrangements.
• Respond to and resolve Network Management inquiries.
• Assemble and analyze historical financial data, identify trends, provide forecasts, explain processes, recommend actions, and improve departmental processes.
• Provide detailed capitation and accrual data for CMS bids on a GAAP-to-incurred basis.
• Provide analytical support to Finance, Network Management, Pharmacy, and Health Care Informatics departments.
• Compile and present complex capitation information, assumptions, and recommendations.
• Initiate membership and payment audits and ensure capitation process efficiency.
• Support SCAN’s Vision and Goals and perform other duties as assigned.

Financial Analyst

Care Coordinator

• Perform assessments and screenings to determine and provide appropriate interventions and referrals
• Act as a triage and starting point of contact with members, providers, and medical groups for administration of benefits/programs and troubleshooting access issues
• Use motivational interviewing techniques to understand and address member goals and concerns
• Coordinate care and services using member benefits and community resources
• Address and resolve access-to-care issues to support better health outcomes and a positive member experience
• Complete timely and accurate documentation, including assessments, care plans, service plans, and case notes, across multiple computer systems
• Coordinate care and services with county offices and governmental agencies as needed
• Demonstrate critical thinking to resolve issues with members, providers, and vendors
• Exhibit professionalism and empathy in interactions with members and provider partners
• Follow department procedures, workflows, job aids, and training materials
• Refer complex issues to higher-level staff while handling basic issues under direct supervision
• Support SCAN’s Vision and Goals and perform other duties as assigned

Care Coordinator – Health Plan

• Assess and screen members to determine and provide appropriate interventions and referrals
• Serve as a triage and starting point of contact with members, providers, and medical groups for administration of benefits/programs and troubleshooting access issues
• Use motivational interviewing to understand and address member goals and concerns
• Coordinate care and services using member benefits and community resources
• Address and resolve access-to-care issues to support health outcomes and member experience
• Complete timely and accurate assessments, care plans, service plans, and case notes in multiple computer systems
• Submit documentation within established timeframes and follow department procedures and training materials
• Apply critical thinking to resolve issues with members, providers, and vendors
• Coordinate with county offices and governmental agencies as needed
• Exhibit professionalism and empathy in member and provider interactions
• Perform work under direct supervision, handling basic issues and referring complex issues to higher-level staff
• Support SCAN’s Vision and Goals
• Perform other duties as assigned

Human Resources

• Direct the day-to-day administration of the Human Resources function
• Structure and integrate shared services, human capital intelligence, people relations, and HR technology to optimize service delivery
• Determine, deploy, and refine the HR functional organization and delivery strategy
• Design, develop, and implement HR services for internal and external customers
• Manage HR projects to solve talent problems and create or upgrade HR resources, practices, and policies
• Develop and implement business-focused HR metrics and deliver workforce reporting and analytics
• Develop and implement an HR technology strategy and oversee automation of HR activities
• Direct people relations services promoting healthy work relationships, fair and equitable treatment, and regulatory compliance
• Lead development and tracking of the overall HR budget
• Review and analyze HR expenditures and adjust budget plans
• Manage outsourced HR services, vetting vendors and holding them accountable to service commitments
• Support SCAN’s Vision and Goals
• Perform other duties as assigned

Grievances and Appeals Coordinator

Financial Analyst

Care Coordinator – Health Plan

Care Coordinator – Health Plan

VP, HR Operations