Peak Health

Manager

• Collaborate closely with the Director, Operational Analytics, across product, operations, medical management, and provider contracting to support and implement high-quality, data-driven decisions.
• Ensure data accuracy and consistent reporting by designing, creating optimal processes and procedures for analytics employees to follow.
• Use advanced data modeling, predictive modeling, and analytical techniques to interpret key findings from company data.
• Build, develop and maintain data models, reporting systems and performance metrics to support key business decisions.
• Support the submission of the Prescription Drug Data Collection (RxDC) Reporting suite of regulatory reports for employer-sponsored group health plans.
• Ensure compliance with all applicable regulatory requirements, guidelines, and contractual obligations set forth by CMS.
• Work closely with Quality, Risk Adjustment, Analytics, Finance, Actuarial, Provider Networking/Relations, and other teams within the company to execute on business objectives.

Manager, Operational Analytics

Compliance

• Participate in and support compliance program activities including monitoring, investigations, exclusion screenings, policy preparation, communications, and training.
• Lead the compilation, tracking and reporting of deliverables; review deliverables for accuracy and facilitate corrections.
• Assist with vendor activities, including documentation of all pre- and annual delegate oversight and ongoing vendor oversight activities.
• Assist with compliance audits and related activities, including tracking documentation, coordination of interviews, and support the preparation of final reports.
• Provide analysis, interpretation, training, and education related to requirements as needed to ensure understanding and effective implementation of compliance requirements.
• Support operational partnerships to ensure compliance with applicable rules and regulations, while supporting a positive member experience.
• Develop and implement process improvement and automation for Compliance Department.
• Investigate issues with effective research, root cause analysis, and gap analysis for effective remediation and corrective action management.
• Maintain and enhance current knowledge of compliance and best practices through attendance of meetings and seminars, study of reference materials, and updates to compliance rules and regulations.

Insurance Compliance Analyst

Actuary

• Guide the development and execution of the entire actuarial function
• Assist in strategic initiatives
• Pricing/underwriting, financial reserving, forecasting, trend analysis
• Support business decisions through a medical economic framework
• Serve as a key advisor to the executive leadership team
• Collaborate with various functions within the organization such as finance, accounting, analytics, product, population health, clinical teams, provider contracting, and client relationship managers

Director, Actuarial Services

Accountant

• Develop strong relationships with Department managers to help coordinate and monitor financial controls over the organization’s cost centers according to approved budget guidelines
• Coordinate accounting and financial processes to maximize efficiency in the daily accounting operations
• Maintain general ledger in order to complete and submit accurate financial data during month-end process
• Lead and coordinate month end variance analysis
• Oversee and review month end general ledger reconciliations
• Oversee the work and development of assigned Accounting Department staff
• Delegate projects/duties as necessary
• Assist in completing and compiling financial support documentation for budget and external audit purposes
• Participate in educational opportunities as provided by the hospital to enhance skill related abilities

Managed Care Accountant

Program Manager

• Develop, maintain, and execute annual audit program
• Ownership of the SIU referral intake and triage process
• Perform investigations into suspected fraud, waste, and abuse
• Leads process and reporting to ensure proper notification of FWA activity
• Identify opportunities for improvement through audit process
• Creation and maintenance of departmental policies and procedures
• Work collaboratively with other departments to educate providers and vendors
• Track, report, and follow-up on overpayments and recoveries
• Collaborate with Compliance, Legal, Claims, and accounting departments
• Serve as a subject matter expert on FWA prevention and detection

Special Investigations Unit Program Manager

Graphics Designer

• Perform a variety of tactical functions to support the timely and successful execution of marketing plans and other activities for the Marketing/Communications Department.
• Design creative and engaging marketing materials, including brochures, fliers, sales collateral, and member materials that communicate key messages about health insurance products.
• Collaborate with the marketing and communication teams to create visually appealing and user-friendly content for both internal and customer-controlled materials.
• Develop and design materials for social media, websites, online ads, and digital presentations that align with our brand identity and marketing strategies.
• Create infographics and visual aids that simplify complex health insurance information, ensuring it is clear and easily understood by our audience.
• Ensure consistency in all design materials, maintaining the integrity of the brand’s voice, tone, and visual identity.
• Edit and prepare files for print, digital publishing, and social media campaigns.
• Responsible for graphic design of Peak Health marketing collateral and other printed pieces, signage, video, and digital marketing tactics.
• Work on projects that support both external marketing and internal communication needs, such as presentations and reports.

Graphic Designer – Marketing Specialist

• Manage and triage self-referrals, identifying high risk members through HRA
• Reporting and admissions data, auditing patient charts of delegated case management programs to meet accreditation standards
• Connect members with in-network providers and resources
• Participate in activities related to care management program build, implementation, oversight, and delegation
• Perform utilization management reviews as needed according to accepted and established criteria, as well as other clinical guidelines and policies
• Assist members in understanding their available medical benefits
• Identify barriers preventing the member from meeting maximum quality of life
• Review and Evaluate Health Risk Assessment (HRA) data to help drive development of programs and services geared toward member needs
• Review and Evaluate member outcomes data and work with other team members on performance improvement opportunities
• Utilizing NCQA standards in auditing processes of member records as part of care management oversight processes
• Investigating potential quality of care issues that may affect the quality or safety of the health of members

Care Manager, RN

• Oversees the build and Implement utilization management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews) that are consistent with established industry and regulatory standards/guidance.
• Manages the build and implement all utilization management reviews according to accepted and established criteria, as well as other clinical and regulatory guidelines and policies.
• Assists in the development and implementation of policies and procedures related to the Utilization Management processes.
• Ensures that utilization management interventions are collaborative and focus on maximizing quality member health care outcomes.
• Supervises the facilitation of the Peer-to-Peer Review process, and work with the Medical Directors to continuously improve member and Provider Network services for this process.
• Oversees the education on utilization management that is provided to internal and external stakeholders and partners to continuously improve processes and build network relationships.
• Facilitates a collaborative environment that focuses on collaboration with other members of the medical management team to identify members whose healthcare outcomes may be enhanced by coaching and/or case management interventions.
• Educates team members on the data that is collected within the position and facilitate improvement in outcomes within the team.
• Assists with monitoring performance standards, productivity and ensuring staff coverage to meet the needs of the department.
• Formulates, implements and evaluates educational strategies for staff.
• Maintains a working knowledge of the requirements of regulatory and compliance entities.
• When needed, fill in for staff members to ensure that the operations of the utilization management team are never compromised.
• Commits to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Management.
• Provides clinical, procedural or interpretational assistance.
• Ability to present complex ideas and data to a wide variety of stakeholders from frontline employees to executive c-suite.
• Other duties as assigned or requested.

Manager, Utilization Management, RN

Customer Support

• Supervises and coordinates activities and employees related to all Enterprise Customer Service and processing including billing, self-pay collections, customer service, and financial counseling of patients within West Virginia Medicine Hospitals, and University Medical labs to ensure the financial viability of the clinical and business enterprise
• Maintain internal controls over accounts receivable records and collection of cash
• Establish and implement controls for submission, billing and payment cycles to ensure integrity of accounts receivable and patient information as well as supervising and controlling cash collected directly from patients
• Negotiate special discount arrangements, using sound financial practices, within the guidelines of State and Federal regulations
• Assures department compliance relating to the extension of credit, billing, and allowable follow-up
• Monitors daily operations to help ensure adherence to documented administrative and departmental policies and procedures
• Coordinates billing operations (including late charge issues, charge issues, coding issues) with other departments and/or outside referral sources/agencies/facilities to ensure continuity of care timely communication and accurate revenue cycle operations
• Identifies on-going continuing education needs of existing employees as well as new employees
• Complete annual reviews as well as 90 day review
• Keeps staff informed of process, policy and other changes through presentation at regular staff meetings, face to face communication and email correspondence
• Provides coaching and counseling to staff based upon performance management principals
• Efficiently and assertively coordinates resolution of problems with other departments as monitored by Manager or Director
• Organizes and executes daily tasks in appropriate priority to achieve optimal productivity, accountability, and efficiency
• Handles patient/family or staff complaints, investigates complaints, and makes recommendations of appropriate resolution
• Works with Manager or Director to develop and attain quarterly objectives
• Maintains confidentiality according to policy when interacting with patients, physicians, families, coworkers and the public regarding demographic/clinical/financial information
• Demonstrates flexibility to meet the needs of the department or hospital in regard to changes in work volume, planned change, scheduling changes, and emergency call – backs (i.e. weather or disaster)
• Maintains currently knowledge of major payor payment provisions
• Displays and understanding of third-party payor regulations related to managed care, denials, and reimbursement issues
• Able to inform patients of hospital and clinic billing practices/polices and their rights and responsibilities regarding payments