Current Job Openings for Healthcare Professionals

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QP Customer Service Specialist


Customer Service Specialist are responsible for assisting providers and members with inquiries related to claims, contracts, authorizations, benefits, services, registries, and community resources. Specialist provide appropriate screening, handling and routing of incoming phone calls with the goal to provide first-call resolution when possible. Specialist are trained in specific functional areas such as member services or provider services and assigned to primary areas of responsibility. Specialists are also cross-trained to handle overall inquiries and provide high-quality customer service.  The role may also initiate outbound calls per established work queues, lists and assignments. The specialist is responsible for documentation of all calls and routing activities for follow up through defined workflows and processes.
Senior Specialist (QP & Non-QP) will provide more complex support for members and/or providers to resolve or troubleshoot questions.  Document calls and routing activities for follow up through defined workflows and processes, including escalation of situations to Contact Center leadership.
Essential Functions
Primary Responsibilities:
Customer Service Specialist (Tier I)
  • Interacts by phone or live chat with providers and members to provide information in response to inquiries, concerns, and questions
  • Performs initial triage of callers needs to determine appropriate handling of the call
  • Schedule member appointments with Network providers or reminding members of appointments
  • Complete referrals to other teams such as member engagement or care coordination to assist members
  • Interact with providers and/or members to provide information in response to inquiries about services and other resources
  • Perform research on billing inquires and claims to inform providers including educating on processes for resolving identified issues
  • Research payment and refund issues, including assigning to specialists for additional follow up
  • Liaison between various departments to address questions and provide basic information about Cardinal Innovations, including processes and where to find information
  • Identify, research, resolve and follow-up on customer inquiries not immediately resolved.
Senior Customer Service Specialist, Non-QP (Tier II)
  • Serves as a subject matter expert for contact center operations based on the line assigned (member services or provider services)
  • Secondary level calls already triaged by the customer service specialist transferred through warm handoffs
  • Assist in the creation of call scripts based on typical inquires, or contractual requirements to improve standard process and customer interactions
  • Responsible for testing new functionality, workflows, scripts, etc. prior to launch with the entire team
  • Assigned to workgroups, special projects, or committees to represent the Contact Center, including bringing back information to the larger team
  • Provide additional coverage for Tier 1 calls or during absences to ensure all the call metrics are maintained
  • Responsible for educating and or providing screening for new members including identification of any Social Determinant of Health needs (SDOH) referring to appropriate resources depending on functional assignment area
  • Complete referrals to other teams for follow up on issues, concerns, or member needs
  • Interacts with providers and/or members to provide information in response to inquiries about services and other resources.
  • May be assigned responsibility for updating materials related to call center operation
Qualifications
Knowledge, Skills, & Abilities:
  • Demonstrate the ability to perform in a highly metric driven environment, maintaining minimum quality scores or better.
  • Ability to navigate through automated information systems to analyze the caller's situation.
  • Ability to adapt and perform in a fast paced, changing environment.
  • Provide high quality customer experience to every caller using the skills active listening and positive customer service.
  • Utilize call scripts, processes, procedures, and workflows to manage all calls appropriately including any that require immediate intervention
  • Ability to understand and carry our oral and written instructions
  • Ability to establish and maintain effective working relationship
  • Strong problem-solving, organizational, and task management skills
  • Knowledge of computer systems such as Word, Excel, Electronic Healthcare Record systems
Education and Work Experience
Education and Experience:
  • Tier I: High School Diploma or equivalent (Associates preferred)
  • Tier II: Associates degree (Bachelors preferred; Masters preferred for QP)
  • Meet all qualification to be established as a Qualified Professional (QP) for behavioral health (QP ONLY)
  • 2 - 4 years face to face customer service or call center environment. (Healthcare preferred)
  • Experience toggling between systems, completing required data entry or member/provider lookups while talking to the caller
Valid Driver’s License Required: No Travel Type: None Required Percentage:   None
Language: Read Write Speak
English
Spanish
Other:
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Pharmacy Director


Pharmacy Director

The Pharmacy Director is responsible for providing a range of clinical support to the Medical, Utilization Management, Care Coordination, and Quality Management departments. Ensure the use of clinical and managed care pharmacy best practices in implementing the integration of both physical and behavioral health intellectual and developmental disabilities (BH/IDD) required for North Carolina Tailored Plan. Manage continued member health and safety through a range of monitoring, consultation, training, and provider outreach activities. This position reports to the Chief Medical Officer.

Essential Functions

Primary Responsibilities:

· Serve as both a medical and behavioral health drug information and therapeutic resource for the staff

· Develop pharmacy services based on nationally recognized evidence-based clinical practice guidelines and decision support methodologies to support UM and medication prior authorizations

· Implement and monitor pharmacy service authorizations on file with the North Carolina Medicaid program, NC Health Choice program, a Standard Plan or BH I/DD Tailored Plan

· Manage the BH I/DD Tailored Plan pharmacy benefits and services to ensure members and providers access to therapeutically needed medications provide the best overall value to members, providers, and the North Carolina Medicaid program

· Advocate and provide information about Opioid Misuse Prevention and Treatment Programs and the Tobacco Cessation Programs

· Support statewide behavioral health initiatives such as A+KIDS, ASAP, Narcotic Lock-in

· Oversee Drug Utilization Review educational programs and outreach to prescribers and pharmacists

· Assist with Cardinal Innovations Healthcare initiatives to improve medication adherence within the covered population.

· Maintain pharmacy services web page to direct providers and members to their PBM’s pharmacy services

· Develop policies and procedures to independently audit payments, eliminate conflicts of interest with affiliated pharmacy providers and monitor PBM performance

· Liaison with the NC Department of Medicaid, PBM and pharmacy providers to resolve issues and rebate issues

· Assist in the development and oversight activities related to improving outcomes for targeted disease management initiatives leading to improved health and ensure NCQA re-accreditation.

· Review and screen high-risk patients identified by internal reports and provide consultation and recommendations to clinical staff

· Provide clinical pharmacy input, with behavioral health emphasis when needed to address complex cases and cases with complex co-morbidity

· Provide highly specialized education and training support for other professional services in the broad area of advanced pharmacotherapy, with emphasis on psychiatric issues

· Attend and provide feedback at team meetings related to pharmacology

· Work with Care Managers and Clinical Coordinators to address patient access to medication post-discharge from EDs and Inpatient units

Qualifications

Knowledge, Skills & Abilities:

· Extensive knowledge of pharmacy and its related sub-disciplines (therapeutics, pharmacology, physical pharmacy), formulary development, drug use review, quality assurance, legal, regulatory, and standards of practice.

· Proficient in electronic health records and various Healthcare such as CMIS applications.

· Responsible for maintaining patient and family confidentiality in accordance with HIPAA.

· Ability to work independently, exercising sound judgment, discretion and the initiative to facilitate change.

· Excellent analytical and problem-solving abilities and interpersonal, written, and verbal communication; the ability to integrate healthcare team.

· Excellent organizational skills, diplomacy, and professionalism.

· Ability to research and analyze the medical literature including drug information, disease states, and clinical practice guidelines.

· Proficiency in using database information systems and Microsoft Office Suite.

· Familiar with values and goals of Cardinal Innovations and minimal daily instruction.

· Motor Vehicle Report (MVR) status meeting current auto carrier’s insurability criteria, required.

· Ability to work flexible hours and travel to local pharmacy as needed.

 

Education and Work Experience

Education and Experience:

· Doctor of Pharmacy (PharmD) from an accredited College of Pharmacy

· Five (5) years experience in Medicaid pharmacy benefits management as a clinical pharmacist with involvement in formulary development, drug use evaluation and quality assurance activities.

· Integrative and psychiatric pharmacy experience preferred.

Valid Driver’s License Required: Yes Travel Type: Domestic Percentage: 5 - 15

Language: Read Write Speak

English ☒ ☒ ☒

Spanish ☐ ☐ ☐

Other: ☐ ☐ ☐

Licensure and/or Certification

· Clinical pharmacy residency (PGY1 or PGY2) preferred or equivalent experience and licensure by North Carolina

Board of Pharmacy.

· Valid Driver license and motor vehicle insurance, required.

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Performance Improvement Specialist


Performance Improvement Specialist
 
Responsible for oversight and plan development of quality improvement initiatives, internal and external education, coordination of improvement projects, conducting data collection, reporting and monitoring of key performance measurement indicators, and providing subject matter expertise regarding quality improvement approaches.  Occasionally this position may be asked to travel to another community office location to maintain coverage.
Essential Functions
Primary Responsibilities:
  • Implementing identified quality strategies, which may include initiation and management of provider, member and/or community interventions (e.g., identifying and removing barriers to care); preparation for quality oversight surveys; and other federal and state required quality activities.
  • Monitoring performance and quality activities for timely completion and accuracy.
  • Preparing and presenting executive and detail level summary of quality activities as needed. 
  • Writing narrative reports to interpret regulatory specifications, explain programs and results of programs, and document findings of department interventions.
  • Creating, managing and/or compiling the required documentation to maintain critical quality improvement functions.
  • Leading quality improvement activities, meetings and discussions with and between other departments within the organization.
  • Evaluating project/program activities and results to identify gaps and opportunities for improvement.
  • Attending meetings/trainings as needed to stay informed of changes in clinical best practices, local, State, Federal and Division requirements.
  • Other tasks, duties, projects and programs as assigned.
Qualifications
Knowledge, Skills, & Abilities:
  • Experience working with quality improvement approaches and strategies
  • High level of diplomacy and discretion is required to effectively negotiate and resolve issues
  • Self-motivated with strong organizational, multi-tasking, planning, and follow up skills.
  • Excellent written and oral communication skills.
  • Demonstrate strong business writing skills.
  • Retain large amounts of information and be able to interpret written rules/regulations.
  • Possess organization skills that allow them to balance a wide variety of task in a time-effective manner. 
  • Demonstrate proficiency in Visio or flow chart equivalent and Microsoft Office products and be able to quickly learn new software tools.
Education and Work Experience
Education and Experience:
  • Bachelor’s Degree in Social Services, Public Health, or Healthcare Administration or in a related field. May substitute for equivalent experience.
  • 3 years of healthcare or behavioral healthcare experience with 1-year experience in health-related quality improvement, or equivalent experience.
  • 1 year of experience in Medicare and/or Medicaid preferred.
  • Formal training in quality improvement techniques preferred.
Valid Driver’s License Required: Yes Travel Type: Domestic Percentage:   0 - 5
Language: Read Write Speak
English
Spanish
Other:
Licensure and/or Certification
Preferred but not required:
  • Certified Professional in Health Quality (CPHQ)
  • Nursing License (RN)
  • Lean Six Sigma certification
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HEDIS Specialist


HEDIS Specialist
Responsible for oversight and plan development for HEDIS-related initiatives, internal and external education, maintenance of programs for members in accordance with HEDIS-related measures, conducting data collection, reporting and monitoring of HEDIS quality measures, and coordination of compliant HEDIS submissions.  Occasionally this position may be asked to travel to another community office location to maintain coverage.
Essential Functions
Primary Responsibilities:
  • Implementing identified HEDIS-related improvement strategies, which may include initiation and management of provider, member and/or community interventions (e.g., identifying and removing barriers to care)
  • Coordination and preparation for HEDIS validation, auditing, and submission.
  • Monitoring performance and HEDIS quality activities for timely completion and accuracy.
  • Preparing and presenting executive and detail level summary of HEDIS-related activities as needed. 
  • Working with internal departments to address gaps in care, coordinate efforts with providers, and document findings of department interventions.
  • Creating, managing and/or compiling the required documentation to coordinate HEDIS-related functions.
  • Leading HEDIS-related improvement activities, meetings and discussions with and between other departments within the organization.
  • Attending meetings/trainings as needed to stay informed of changes in HEDIS measurement requirements and best practices.
  • Other tasks, duties, projects and programs as assigned.
Qualifications
Knowledge, Skills, & Abilities:
  • Experience working with HEDIS software vendors (management, building relationships, issue resolution, etc.).
  • High level of diplomacy and discretion is required to effectively negotiate and resolve issues
  • Self-motivated with strong organizational, multi-tasking, planning, and follow up skills.
  • Excellent written and oral communication skills.
  • Demonstrate strong business writing skills.
  • Retain large amounts of information and be able to interpret written rules/regulations.
  • Possess organization skills that allow them to balance a wide variety of task in a time-effective manner. 
  • Demonstrate proficiency in Visio or flow chart equivalent and Microsoft Office products and be able to quickly learn new software tools.
Education and Work Experience
Education and Experience:
  • Bachelor’s Degree in Social Services, Public Health, or Healthcare Administration or in a related field. May substitute for equivalent experience.
  • 2 years of experience managing HEDIS outcomes with a health plan, behavioral health plan, or HEDIS-related vendor
  • 1 year of experience in Medicare and/or Medicaid preferred.
  • Project Management experienced preferred.
Valid Driver’s License Required: Yes Travel Type: Domestic Percentage:   0 - 5
Language: Read Write Speak
English
Spanish
Other:
Licensure and/or Certification
Preferred but not required:
  • Certified Professional in Health Quality (CPHQ)
  • Nursing License (RN)
  • Certified HEDIS Compliance Auditor (CHCA)
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Access Clinical Supervisor


Access Clinical Supervisor 

This Supervisor provides day to day oversight of call center operations (24/7/365), including monitoring performance metrics. The Supervisor ensures appropriate coverage for all shifts, call lines, schedule adjustments, and call routing to manage volume between lines to fully support the fast-paced call center. The Supervisor ensures high-quality customer service is provided to callers, through developed processes, protocols, and call scripts. The employee will act as one of the Supervisors for call center operations, including the Access Crisis Line, and the provider and member service lines. Other supervisory responsibilities include the completion of all required Human Resources documentation as per procedures. This position will also provide direct services covering calls as needed to support overall operations and act as the back-up contact for members requesting behavioral health services.

Essential Functions:

The Access Clinical Supervisor is responsible for (though not limited to)

· Assisting in the creation and maintenance of daily schedules to provide consistent staffing for the workload of the Access team. This includes maintaining adequate FTEs to handle all work volume.

· Act as the primary point of contact for support to line staff when facing an issue related to call handling and/or general referral practices.

· Monitors assigned staff performance, inclusive of monitoring against expected metrics and development of action plans when necessary

· Monitoring interactive technology and report any problems to the appropriate leadership staff within the department as well as other business units such as Infrastructure Technology (IT) Department

· Completing and ensuring that staff complete all required documentation based on established requirements, inclusive of ensuring the incorrect information is updated for appropriate tracking

· Providing initial and ongoing orientation, training and supervision for staff.

· Complete training and other reimbursement requests submitted by staff.

· Complete calendar time off requests and training requests for staff, making sure to update the shared schedule spreadsheet, ensuring that any operating procedure related to coverage are followed.

· Complete and provide supervision summary to staff monthly drawing upon audit results and call statistics.

· Develop and implement Corrective Action Plans (CAPs) as needed

· Conduct monthly and or quarterly blind call audits and documentation audits on staff at designated intervals

· Monitor and support developing performance goals and providing coaching/support/intervention as needed to promote success. Provide supervision summary to staff for the month’s prior outcomes or before and complete appropriate documentation of the supervision

· Provide daily phone consultation support and via instant messaging applications for support as needed by staff for call handling.

· Review all adverse event notifications provided by staff and provide review in the corresponding notes. Provide validation/verification of all adverse event calls. Provide weekly verification of adverse event, other and non-threshold call notes. Appropriate labeling of corresponding call notes and follow up on any corrections needed with staff and/or the log entries. · Act as the Subject Matter Experts (SMEs) on all referral and call handling procedure activities – other, non-threshold, routine, urgent, emergent, transfer processes, etc. · May be responsible for overseeing specialty projects, participation in committees, etc. to support the overall organization · Other tasks, duties, or assignments per directive of Access Leadership. · This is a highly independent position. This position requires adaptability of the staff to meet and prioritize the needs within the busy call center setting. Staff report directly to the Access Coordinator Manager. Regular supervision will be scheduled. Attendance to Monthly Staff meetings and other mandatory meetings and trainings are required.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

· Knowledge of Call Center practices and operations, inclusive of call routing, call tiering, and managing multiple lines simultaneously.

· Knowledge of quality improvement indicators and procedures.

· Comprehensive knowledge and experience in working with various computer programs including Microsoft Word, Excel, and Cardinal Innovations. Ability to navigate multiple computer systems.

· Ability to work evenings and weekends

· Knowledge of clinical protocols to ensure referrals to appropriate level of care.

· Knowledge of community resources outside of mental health; substance abuse and developmental disability to provide diversions to alternative care when applicable.

· Therapeutic and crisis intervention experience; Knowledge of available resources within the served catchment areas.

· Strong clinical knowledge of diagnosis, best practices, and various screening tools

· Ability to provide Administrative On Call coverage in rotation with other members of the Access Leadership team.

· Strong customer service skills required

 

Education and Work Experience:

Education and Experience: Master’s Degree in Social Work or related field with at least 2 years post-licensure experience in a Mental Health, Intellectual Disability / Developmental Disability and/or Substance Abuse setting. Requires a current
North Carolina Clinical License. Prior call center experience preferred

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