Peak Health

Consultant

• Develop and maintain collaborative relationships with providers, including physicians, hospitals, ancillary providers, and vendors
• Shape the provider network landscape through objective data and education across stakeholders and product lines
• Educate providers on credentialing, contracting, authorizations, referrals, claims and encounters, grievances and appeals, health education, population health, care management, pharmacy management, electronic health records, health information exchange, data exchange, and regulatory updates
• Conduct provider outreach through email, telephone, in-person meetings, and webinars
• Assess provider efficiencies when interacting with the health plan
• Conduct initial provider orientations and ongoing educational outreach
• Conduct group training sessions
• Assist with provider contract questions, research problems, and resolve escalated issues
• Represent the health plan at healthcare association functions
• Participate in regulatory reporting for provider networks
• Monitor competitors and market regulations
• Support strategic positioning to develop and maintain provider networks
• Assist the Credentialing Department with difficult-to-obtain documents
• Collaborate with Claims Operations, Medical Management, Credentialing, Contracting, Legal, Analytics, Compliance, Sales and Marketing, and Member and Provider Service teams
• Report to the Manager Network Services as a member of the Provider Relations team

Network Service Consultant

Manager

• Provide coordination of care to SNP members, including establishing and maintaining care plans
• Coordinate care with Interdisciplinary Care Team members and during transitions of care
• Participate in care management program build, implementation, oversight, and delegation
• Conduct intake assessments with members and families
• Develop individualized care plans accounting for physical, financial, and other constraints
• Serve as liaison for the Interdisciplinary Care Team with PCPs and beneficiaries/caregivers
• Provide resources and benefits education to beneficiaries/caregivers to improve self-management and quality of life
• Collaborate with care management team members to support beneficiaries through transitions of care
• Act as primary contact for members/caregivers, PCPs, specialists, and ancillary providers
• Audit member records using NCQA standards
• Review Health Risk Assessment data to guide programs and services
• Manage and triage member self-referrals to care management programs
• Participate in case management and quality committees
• Review medical records and investigate potential quality-of-care issues
• Assist with quarterly reporting of delegated case management processes
• Connect members with in-network providers and community resources
• Identify barriers to members achieving maximum quality of life
• Perform virtual face-to-face visits when needed
• Help ensure compliance with CMS SNP Model of Care, NCQA standards, and Medicare Advantage requirements

Care Manager – SNP

Analyst

• Review, execute, and oversee member enrollment application information processing for Peak Health’s Plan Suite
• Manage weekly enrollment files and daily ACA/Marketplace enrollment transactions
• Process new enrollments, maintenance transactions, cancellations, terminations, reinstatements, plan changes, and SEP requests
• Reconcile membership, coverage, Marketplace, CMS, and issuer records; resolve discrepancies, errors, rejects, and exceptions
• Maintain member enrollment records, APTC/CSR information, databases, and work queues
• Validate applicant eligibility, household information, coverage effective dates, enrollment status, and supporting documentation
• Process and research SNP, ACA/FFM, Medicare, and ASO enrollment applications and transactions
• Complete EDV monthly processes, REED submissions, CMS reconciliations, LEP data files, and MPWR files
• Monitor production and quality standards and conduct audits for regulatory compliance
• Respond to member inquiries regarding enrollment procedures, benefits, and eligibility
• Develop and deliver enrollment training for new hires and maintain job aids and standard operating procedures
• Participate in system testing, UAT, validation activities, Open Enrollment planning, and process improvement initiatives
• Analyze enrollment data, prepare management reports, identify trends and discrepancies, and recommend improvements
• Collaborate with underwriting, billing, customer service, Marketplace representatives, vendors, and other stakeholders
• Escalate issues appropriately and troubleshoot enrollment system problems

Enrollment Analyst – ACA Enrollment

Accountant

• Perform monthly accounting for member premium revenue, including accruals, adjustments, and deferrals
• Reconcile premium billing systems to the general ledger and resolve discrepancies
• Analyze premium receivables, cash applications, and aging
• Monitor and report on unapplied cash and premium variances
• Prepare journal entries and account reconciliations under GAAP and statutory accounting principles
• Support monthly, quarterly, and year-end close processes
• Assist with regulatory reporting requirements
• Ensure compliance with internal controls, SOX requirements, and audit standards
• Investigate and resolve premium issues, including eligibility discrepancies, retroactive adjustments, and billing errors
• Partner with Enrollment, Billing, Actuarial, and IT teams to address discrepancy root causes
• Perform trend analysis on premium revenue and membership data
• Support system implementations, upgrades, premium-rate loading, and testing
• Identify and implement process improvements
• Maintain accounting workflow and procedure documentation
• Assist internal and external auditors with premium-related documentation and explanations
• Support ad hoc financial analysis and special projects
• Coordinate with Enrollment regarding member grace periods and policy development
• Manage a queue of CRMs related to member premiums
• Support billing and collection activities for third-party administration and group insurance customers
• Assist with materials and education concerning premium invoice payment options

Revenue Accountant

Business Intelligence Developer

• Assists with the development, scaling, improvement, and maintenance of data models, dashboards, and analytical solutions supporting Peak Health operations
• Leverages complex analytical tools to provide business and technical expertise to create data driven solutions.
• Partners with product, operations, medical management, and provider contracting teams to understand & anticipate reporting requirements, priorities, and key performance indicators.
• Supports key business stakeholders, translating data into actionable insights using appropriate analytical solutions.
• Produces repeatable and ad-hoc reports for key business stakeholders to measure and interpret business trends.
• Participates in a variety of assigned operations initiatives to ensure success in meeting business goals and objectives.
• Collects report requirements – interviews and researches business stakeholder needs; drafts, edits and validates requirement documentation.
• Provides input on project plans, scope of work, status, and project summary reports.
• Communicates results of analysis effectively and regularly to business stakeholders.
• Other duties as assigned.

Business Intelligence Engineer

Social Worker

• Participate in activities related to care management program build, implementation, oversight, and delegation.
• Assist in ensuring compliance with CMS SNP Model of Care (MOC) expectations, NCQA standards, and Medicare Advantage regulatory requirements.
• Perform psychological, social and economic care management interventions for members with severe/persistent mental or emotional disorders.
• Perform telephonic behavioral health comprehensive assessments of members’ environmental, behavioral, psychological, economic and social factors.
• Assist in the development of individualized and culturally sensitive care plans in collaboration with the member’s assigned CM, identifying problems, interventions, barriers and goals.
• Performing telephonic re-assessments, care plan revisions and evaluating the effectiveness of the members’ care plan.
• Member of the ICT for members with SDOH and BH needs and participates in ICT meetings when appropriate.
• Recognizes early signs of a members’ decompensation that requires immediate case management intervention that promotes and motivates compliance with treatment plan.
• Serves as an additional point of contact during transitions of care.
• Co-manages member cases with the CM to address psycho-social, economic and cultural issues that may impact the members’ care needs.
• Serves as a primary socio-economic resource for the D-SNP Care Management Team.
• Documents in the members’ case accurately and timely to ensure coordination of the members’ care needs.
• Adheres to all CMS, Code of Federal Regulations, local/state/national regulatory requirements and guidelines as well as those outlined within the MOC.
• Collaborate with all members of the interdisciplinary care team to facilitate appropriate community resource assistance for members with identified needs.
• Screens, identifies, diagnoses, treats and manages mental health and/or substance abuse problems in patients and family members.
• Knowledge of hospital, medical center and/or health system resources to access and provide for patient care needs.
• Maintains a working knowledge of community agencies and resources and serves as a liaison between them and the healthcare system.
• Collaborates for appropriate resource and financial management which may include but is not limited to-financial assistance coordination/referrals, entitlement program coordination/referrals, or patient benefit coordination.

SNP Social Worker – Peak

• Identify and connect high risk members to appropriate resources and programs to achieve optimal quality and financial outcomes.
• Manage and triage self-referrals and identify high risk members through HRA, reporting and admissions data.
• Audit patient charts of delegated case management programs to meet accreditation standards.
• Connect members with in-network providers and resources.
• Assist in utilization management reviews and ensure quality standards in auditing processes.
• Participate in case management and quality committees.