WVU Medicine

Supervisor

• Supervise and coordinate the daily operations and performance of a Medicare Member Services call center team
• Provide leadership, coaching, counseling, recognition, corrective action, and operational oversight
• Monitor call volumes, service levels, average speed of answer, abandonment rates, schedule adherence, quality, productivity, and other performance measures
• Ensure accurate information is provided regarding Medicare Advantage and D-SNP benefits, eligibility, enrollment, claims, authorizations, provider access, pharmacy coverage, grievances, and appeals
• Ensure compliance with CMS requirements, Medicare and Medicaid regulations, D-SNP requirements, HIPAA, organizational policies, and applicable state and federal regulations
• Monitor calls, CRM records, and member documentation for accuracy, completeness, professionalism, and compliance
• Identify training and continuing education needs; support onboarding, mentoring, and transition to independent call handling
• Complete performance evaluations, reviews, one-on-one meetings, and employee assessments
• Communicate benefit, process, policy, regulatory, system, and operational changes to staff
• Oversee SharePoint and other approved 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 Information Technology
• Handle escalated member, provider, authorized representative, and internal staff concerns and facilitate timely, compliant resolutions
• Identify and appropriately document and refer complaints, grievances, appeals, coverage concerns, and compliance issues
• Work with the Manager or Director on departmental goals, performance standards, objectives, quality-improvement initiatives, and strategic priorities
• Maintain confidentiality and protect personally identifiable information and protected health information
• Review operational reports, quality findings, call-monitoring results, feedback, complaints, and compliance concerns to implement corrective or preventive actions
• Manage employee schedules, attendance, timekeeping, paid-time-off requests, breaks, lunch adherence, and staffing coverage
• Participate in recruitment, interviewing, selection, onboarding, and retention of Medicare Member Services representatives
• Promote a professional, collaborative, inclusive, accountable, and member-focused work environment
• Perform other duties as assigned

Supervisor, Medicare Member Services

Accountant

• Support WVU Medicine’s budget process, including data entry and analysis
• Complete and compile financial support documentation for budgets
• Evaluate financial processes and reports and implement efficiency improvements
• Develop and submit analytical financial data and information for department leaders
• Perform department reconciliations and analysis
• Perform accounting-related functions and submit accurate financial data during month-end processes
• Perform billing for various departments
• Perform accounts receivable reconciliations and analysis
• Perform productivity analysis and reporting
• Support performance improvement and quality assurance initiatives

Accountant I

Referral Specialist

• Collect comprehensive, detailed patient medical information and determine the need for nursing intervention
• Expedite care for urgent patients
• Interpret and apply policies and procedures
• Provide financial education regarding benefits and personal financial liability
• Obtain insurance verification and pre-certification
• Coordinate single case agreements and third-party payer contracts
• Schedule appointments and tests across departments, clinics, and private medical offices
• Coordinate medical information, records, and films for upcoming appointments
• Communicate patient status with internal and external providers
• Answer patient phone calls and address concerns and needs
• Capture accurate patient information for medical triage of spine referrals using Cordata and physician protocols
• Identify and process urgent patients and services requiring pre-certification or pre-authorization
• Obtain external medical records and transfer them to HIM and Cordata
• Enter demographic, billing, and insurance information into registration and billing systems
• Verify eligibility and benefits with insurance companies
• Advise patients, referring physicians, insurance companies, or providers about coverage issues and financial responsibility
• Obtain Workers Compensation authorization and document authorization details
• Refer WVU Cares/self-pay patients to financial counselors
• Schedule clinic appointments using Epic and communicate appointment details and instructions
• Flag patient accounts for special notifications and inform clinics of assistive-device needs
• Respond to and resolve patient and referring physician/office needs and complaints
• Record referral and physician information in Cordata and update the Referring Physician Database via Ruby-on-Line
• Identify duplicate Epic files and coordinate resolution with HIM
• Participate in performance improvement, educational programs, and departmental meetings

Referral Specialist – Spine Center

Nurse

• Collaborate with the Medical Director to decrease care variance and ensure timely discharges
• Refer members to other plan resources to meet their care conditions
• Report to the Health Plan Manager of Utilization Management
• Serve as an integral member and collaborative contributor 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 collaborative interventions focused on maximizing members’ healthcare outcomes
• Understand and support the Peer-to-Peer Review process with Medical Directors
• 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
• Pursue continuous learning and process improvement across Utilization Management

Utilization Review Nurse

QA Engineer

• Coordinate the day-to-day quality, safety, and compliance program at Mon EMS
• Extract, analyze, and disseminate EMS data for quality assurance and quality improvement programs
• Build reports and review clinical performance reporting
• Coordinate and conduct individual case reviews and investigate incidents
• Foster patient and employee safety, continuous improvement, error reduction, efficiency, and improved patient outcomes
• Support leadership and operations in reducing costs, enhancing revenues, and achieving utilization and quality objectives
• Perform risk management, corporate compliance, and HIPAA privacy responsibilities as required
• Plan and deliver training with the Clinical Services education team to enhance clinical care
• Review EMS personnel reports for accuracy, completeness, and policy/protocol compliance
• Conduct case reviews and evaluate 911 communications for protocol compliance
• Monitor EMS system and personnel performance and provide patient-care feedback
• Design quality assurance and quality improvement evaluation methodologies
• Analyze Computer-Aided Dispatch data for response-time and resource-utilization trends
• Recommend training updates for personnel or the department
• Support initial and continuing education, new-hire classes, and other training programs
• Collaborate with Medical Directors and Mon EMS leadership on clinical remediation and standards of practice
• Serve as liaison for customer concerns involving clinical matters
• Conduct research, data collection, and written reporting
• Review and recommend patient-care guidelines, policies, and operational procedures
• Conduct compliance audits against laws, regulations, company policies, and WV OEMS standards
• Present evidence-based quality indicators and standards and support implementation of improvement initiatives
• Develop dashboards, scorecards, reports, charts, and infographics for quality metrics, performance initiatives, and regulatory reporting
• Investigate sentinel events, patient-safety concerns, complaints, and deficiencies in standards of care
• Maintain security and privacy of company and patient information in accordance with HIPAA and applicable regulations

Quality Assurance Analyst

Claims Specialist

• Manage patient account balances, including accurate claim submission, regulatory compliance, timely follow-up, and denial management
• Provide customer support and resolve issues arising from customer inquiries
• Complete reports and clerical duties as needed
• Submit accurate and timely claims to third-party payers
• Resolve claim edits and account errors before claim submission
• Follow up with third-party payers to support collections and department goals
• Gather statistics and complete reports
• Organize and prioritize daily tasks to optimize productivity, accountability, and efficiency
• Follow HIPAA regulations and Notices of Privacy Practices regarding PHI and claim submission/follow-up
• Contact third-party payers to resolve unpaid claims
• Use payer portals and websites to verify claim status and conduct account follow-up
• Assist Patient Access and Care Management with denial investigation and resolution
• Attend educational programs, department meetings, teleconferences, and webcasts as necessary
• Research and process mail returns and payer-rejected claims
• Reconcile billing account transactions and process billing/follow-up transactions accurately and timely
• Maintain knowledge of federal, state, and local hospital-billing regulations
• Monitor accounts to facilitate timely follow-up and payment and maximize cash receipts
• Maintain work queue volumes and productivity within established guidelines
• Provide excellent customer service to patients, visitors, and employees
• Participate in performance improvement initiatives
• Work with supervisor and manager to develop and exceed annual goals
• Maintain confidentiality regarding demographic, clinical, and financial information
• Communicate workflow problems to management in a timely manner

Insurance Claims Specialist

Insurance

• Obtain authorizations for elective procedures, services, and tests to financially clear patients before services are rendered
• Use payor resources, medical policies, and reference materials to verify prior authorization requirements
• Code cases and review clinical documentation for completeness
• Escalate financial clearance risks in compliance with the Financial Clearance Program
• Identify patients requiring pre-certification or pre-authorization
• Contact insurance companies or employers to determine eligibility and benefits
• Use EPIC work queues to obtain authorizations for referrals, tests, and surgeries within expected timeframes
• Follow up on authorization requests, peer-to-peer reviews, denials, and prior authorization appeals
• Ensure diagnosis, procedure, and facility coding align with obtained authorization
• Verify services promptly to avoid treatment delays and reduce administrative time
• Assist Patient Financial Services with denial management and obtain retro-authorizations as needed
• Notify scheduling staff and physicians of cases not authorized within department policy
• Maintain compliance with quality standards and productivity measures
• Collaborate with physicians, financial clearance counselors, schedulers, nurses, patients, families, and other contacts
• Maintain EPIC in-baskets and Outlook emails
• Participate in monthly team meetings and one-on-ones
• Follow established workflows and communicate process or system deficiencies to supervisors or managers
• Maintain confidentiality of demographic, clinical, and financial information

Insurance Authorization Specialist II

• Supervise laboratory services, personnel, and day-to-day workflow in assigned areas
• Assist managers with supervision, personnel coverage, staffing, orientation, performance appraisals, disciplinary actions, and terminations
• Coordinate reference laboratory specimens and ensure results are received within specified time frames
• Coordinate computer downtime activities with LIS personnel and technical staff
• Operate and supervise laboratory equipment and prepare patient specimens according to procedures
• Provide input for developing and revising standard operating procedures and department policies
• Apply hospital, laboratory, administrative, safety, and collective bargaining policies
• Respond to customer inquiries and monitor customer service, specimen processing, and phlebotomy activities
• Consult medical, administrative, and laboratory management regarding technical issues, training, quality assurance, and quality control
• Organize workload, staffing, materials, and resources to support patient care and efficiency
• Participate in staff meetings, in-services, and communication of information to laboratory and clinical personnel
• Review quality control records and test results for analytical errors, shifts, and trends
• Ensure daily workload completion within established turnaround times
• Communicate with laboratory personnel, hospital departments, patients, and the public to resolve problems
• May instruct, supervise, and evaluate medical residents and students

Histology Supervisor

Physician

• Provide Radiation Oncology patient care across Northern Region sites
• Cover Wheeling Hospital, Berkley Medical Center, Ruby Memorial Hospital (MBRCC), Fairmont Medical Center, and United Hospital Center
• Teach medical students, residents, and fellows
• Practice across multiple Northern Region locations in West Virginia

Physician – Radiation Oncologist, Part Time

Human Resources

• Partner with departmental leadership to develop, drive, and execute HR best-practice policies, programs, and training
• Provide HR advisory, coaching, and solutions to functional and business leaders
• Attend department meetings to understand business activities
• Support change management across business/service lines
• Drive talent growth initiatives through talent assessment and career development
• Lead workforce planning, including data reporting, gap analysis, action plans, and monitoring
• Partner with leaders on succession and replacement planning programs
• Develop policies, procedures, training, tools, and reports for succession planning
• Facilitate talent reviews and succession-planning discussions
• Collaborate with the CEOD team on talent development programs
• Monitor succession-plan data integrity in the HRIS and recommend process enhancements
• Develop and implement employee retention strategies and programs
• Conduct exit interviews and employee or management focus groups and analyze trends
• Promote employee engagement and help management interpret engagement survey results
• Work with compensation, benefits, employee relations, CEOD, and disability management disciplines
• Assist in administering 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 further information
• Verify member information while addressing general questions
• Resolve issues and inquiries to ensure an efficient and seamless member experience
• Maintain member communications and perform 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 classes and demonstrate proficiency
• Maintain accurate documents, including timekeeping records

Medicare Member Services Representative

Social Worker

• Provide social work services to patients, families, and significant others through counseling, emotional support, environmental assistance, crisis intervention, and group leadership
• Conduct psychosocial assessments to identify emotional, social, and community strengths and problems
• Participate as a professional member of interdisciplinary treatment teams led by physicians
• Formulate, develop, and implement comprehensive treatment plans using evidence-based treatments and interventions
• Screen, educate, and provide therapy and interventions for substance abuse, depression, anxiety, thought disorders, trauma, and autism spectrum presentations
• Provide consultative services to healthcare team members and maintain knowledge of relevant medical/legal issues
• Educate patients and families regarding adaptation to diagnoses, illness, treatment, and life situations
• Represent the clinical social work perspective and serve as a liaison with patients, families, community agencies, and resources
• Develop discharge plans from admission through length of stay
• Facilitate cognitive/psychoeducational groups, individual solution-focused brief therapy, and crisis intervention
• Provide updates to families, support persons, and care providers and facilitate family meetings
• Facilitate referrals to placement options including personal care homes, nursing homes, skilled rehabilitation, assisted living, and group homes
• Document assessments, plans, interactions, and interventions in accordance with organizational guidelines
• Maintain electronic medical records and participate in staff, committee, department, and administrative meetings

Social Worker – Population Health

• Provide social work services to patients, families, and significant others through counseling, emotional support, environmental assistance, crisis intervention, and group leadership
• Conduct psychosocial assessments of patients and families
• Participate as an interdisciplinary treatment team member led by a physician
• Develop and implement comprehensive treatment plans using evidence-based treatments and interventions
• Screen, educate, and provide therapy and interventions for substance abuse, depression, anxiety, thought disorders, trauma, and autism spectrum presentations
• Provide consultative services to healthcare team members
• Educate patients and families about adapting to diagnoses, illness, treatment, and life situations
• Participate in multidisciplinary healthcare teams and serve as a clinical social work liaison
• Develop discharge plans from admission through length of stay
• Liaise with community agencies and resources
• Facilitate cognitive/psychoeducational groups, individual solution-focused brief therapy, and crisis intervention
• Provide updates to families, support persons, and care providers; facilitate family meetings
• Facilitate referrals to placement options
• Document assessments, plans, interactions, and interventions
• Maintain electronic medical records and participate in staff, committee, department, and administrative meetings

Physician Assistant

• Perform basic nursing skills under the direction and supervision of the practice physician, advanced practice professional, and/or registered nursing staff
• Greet and escort patients to exam rooms; obtain initial information and vital signs
• Prepare exam rooms, ensuring cleanliness and adequate supplies
• Assist with and/or perform exams, tests, and procedures
• Schedule appointments and arrange referral contacts
• Assist providers during patient examinations and procedures
• Educate patients on follow-up expectations
• Maintain quality control testing logs
• Ensure medical equipment is in proper working condition
• Assist patients with completing medical documentation

Certified Medical Assistant – Cancer Center

Financial Planning and Analysis

• Support Pharmacy Department operational efficiency through fiscal management, data analysis, and departmental statistics and reports
• Perform billing, accounting, financial reconciliation, budgeting, forecasting, and variance analysis
• Review medication purchases, revenue, contract pharmacy fees, pricing, compliance, and savings opportunities
• Coordinate 340B split billing, split matching, contract pharmacy tracking, and financial reporting across System entities
• Generate budget, expense, pharmacy spend advisor, cost savings, and year-end reports
• Provide data supporting drug utilization, purchasing, billing, reimbursement, and performance improvement
• Identify irregular spending, system failures, negative 340B accumulation, and opportunities for practice changes
• Collaborate with pharmacy management, hospital departments, vendors, and the System Director of Pharmacies
• Support budgets, external audits, departmental goals, committees, task forces, projects, and education of 340B professionals
• Maintain financial records, policies and procedures, safeguards, system integrity, ordering processes, invoices, shipping, and inventory processes