GLOBALHEALTH HOLDINGS LLC

Role Description The successful candidate will utilize and further develop their existing expertise in Medicare Advantage enrollment processes and guidelines. This candidate will perform advanced functions of enrollment and eligibility to provide exceptional service to members and cross-functional teams. Responsibilities include: - Review enrollment requests and other documents of Medicare beneficiaries applying for Medicare Advantage products. - Perform all functions of verification for SNP enrollees and members. - Process Transaction Reply Reports (TRR) and follow through with documentation and notifications. - Investigate, resolve, and report problems through customer service ticketing or other electronic methods. - Perform premium billing functions and reconciliation according to CMS guidelines. - Perform other duties as assigned. Qualifications - High school diploma or equivalent. - Bachelor's degree preferred. - 5+ years experience in a Medicare Advantage health plan is required. - 5+ years experience in Enrollment processes for a Medicare Advantage health plan is strongly desired. - 5+ years experience in TRR processing and clearing CMS rejections is preferred. - 2+ years experience in Medicare Advantage SNP verification is preferred. Requirements - Strong attention to detail and good organization and time management skills. - Knowledge of Microsoft software programs including Word, Excel, and PowerPoint. - Ability to communicate clearly and effectively, both orally and in writing. - Proven ability to work independently or as a member of a team. - Knowledge of Medicare Managed Care Plans required. - Microsoft Office proficient, including the ability to save and send documents, spreadsheets, and emails. Company Description GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve.

Role Description This position, under the direction of the Supervisor, Care Management, performs and manages all aspects of care management to improve the long-term wellness of members, becoming an advocate for our members through coordination of care. - Conducts telephonic case management for complex, high-risk members to include identification and assessment of needs, planning and coordination of care, and monitoring outcomes in accordance with GlobalHealth and the departments policies and procedures. - Coordinates with providers when applicable to ensure holistic, healthy, beneficial outcomes. - Communicates with respect to family culture, ethnic origin, race, language, gender, age, religion, socioeconomic status, sexual orientation, mental and/or physical challenges. - Through interdepartmental communication, network communication, and member outreach the Case Manager remains aware of patient needs and changes in condition, providing patient advocacy, support, assessing and ensuring quality care, and providing crisis intervention. - Coordination of services for members, including community resources and collaboration with other members of the care team. - Educate members and their caregivers on conditions and self-management techniques. - Initiate and participate in all elements of the SNP MOC, including completing HRA, creating ICP, and initiating ICT. - Complete TOC activities to include post-discharge assessment, medication reconciliation/review, and ensuring member has access to follow up care. Qualifications - Active Registered Nurse license in the state of Oklahoma required. - Active multi-state RN license is preferred. - Previous experience in managed care/utilization management preferred. - Knowledge of current nursing processes, techniques, and established standards, including disease management, medications, and community resources. - Strong attention to detail and good organization and time management skills, including ability to multi-task, learn new skills and reach set goals. - Must be able to communicate, both orally and in writing, clearly and effectively. - Knowledge of Microsoft software programs including Word, Excel, and PowerPoint. - Proven ability to work independently or as a member of a team. Work Environment Current work environment is remote, however, some state exclusions apply. Must have access to a reliable and secured internet connection source. Work environment must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy. This position will also be required to use reasonable and necessary safeguards to protect GlobalHealth records from unauthorized access, disclosure or damage and will adhere to all GlobalHealth privacy and security policies. Other Duties This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Role Description The Manager, Eligibility position reports directly to the Director, Enrollment & Fulfillment and is primarily responsible for managing enrollment activities to facilitate and enhance the company’s operational and financial goals. Responsibilities include: - Preparation and timely processing of enrollment applications, management, and maintenance in accordance with CMS regulations. - Overseeing enrollment activities and reconciliation. - Strong knowledge of the Enrollment process along with State, Federal, and business regulatory requirements. - Ensuring quality control of data entered into membership database and sent to external vendors. - Overseeing and participating in state, federal, and internal audits, as needed. - Accurate and timely dissemination of eligibility data to the network, ancillary providers, and internal systems. - Partnering with external vendors for contracts related to Medicare enrollment file transactions to CMS, ID Card printing, and mailing. - Overseeing external vendors on the development and implementation of initiatives to improve retention efforts among current members. - Ensuring staff compliance with regulatory and company guidelines, including HIPAA compliance. - Partnering with the Director, Enrollment and Fulfillment to establish departmental goals and objectives. - Developing performance competencies and metrics aligned with business goals. - Managing the auditing of enrollment and disenrollment information data. - Creating and implementing policies, procedures, workflows, and job aides for training. - Reconciling monthly payments and discrepancies between data submitted to CMS and GlobalHealth records. - Coordinating and managing the generation and mailing of necessary correspondence relating to enrollment. - Communicating and following up on files delayed by CMS or State. - Reviewing and analyzing all State agency reports/rosters/premium files for eligibility validation. - Performing other duties as assigned. Qualifications - Bachelor’s Degree required. - 3+ years Enrollment Processing related experience in Managed Care or Medicare setting. - Experience processing CMS Transaction Files. - Proficient with Microsoft Office applications, including Word, Excel, Outlook, and various database applications. - Detail-oriented with problem-solving abilities. - Strong and effective verbal and written communication skills. - Exemplary interpersonal and customer service skills. - Good judgment, organization, prioritization, and time management skills. - Proven leadership with staff, projects, and management. - Strategic thinking abilities and analytical skills. - Ability to present written information and findings clearly. Requirements - Strong understanding of eligibility and enrollment transactions in health care/managed care industry. - Ability to perform essential job functions with a high degree of independence and flexibility. - Ability to function effectively under stress and conflicting demands. - Ability to multi-task, set priorities, and manage time effectively. - Intermediate accurate keyboarding skills. - Ability to function in a fast-paced, detail-oriented environment. - Efficiency in MS Office Suite (Word, Outlook, Excel). Work Environment Work is normally performed in a professional office setting with a moderate noise level. It involves standing and walking for brief periods, but most duties are performed from a seated position. Normal vision and hearing are required, along with finger dexterity and eye-hand coordination to operate a computer keyboard. Travel No travel is expected for this position. Supervisory Responsibility This position reports directly to the Director, Enrollment & Fulfillment and is responsible for the supervision of the Enrollment team. Expected to work collaboratively with other departments. Other Duties This job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

Role Description This position, under the direction of the Supervisor, Care Management, performs and manages all aspects of care management to improve the long-term wellness of members, becoming an advocate for our members through coordination of care. Qualifications - Active Licensed Practical Nurse in the state of Oklahoma required - Active multi-state license is preferred - Previous experience in managed care/utilization management preferred Requirements - Conducts telephonic case management for complex, high-risk members to include identification and assessment of needs, planning and coordination of care, and monitoring outcomes in accordance with GlobalHealth and the departments policies and procedures. - Coordinates with providers when applicable to ensure holistic, healthy, beneficial outcomes. - Communicates with respect to family culture, ethnic origin, race, language, gender, age, religion, socioeconomic status, sexual orientation, mental and/or physical challenges. - Through interdepartmental communication, network communication, and member outreach the Case Manager remains aware of patient needs and changes in condition, providing patient advocacy, support, assessing and ensuring quality care, and providing crisis intervention. - Coordination of services for members, including community resources and collaboration with other members of the care team. - Educate members and their caregivers on conditions and self-management techniques. - Participate in elements of the SNP MOC, including completing HRA and working with the member to reach desired goals, under the direction of the assigned Case Manager. - Complete TOC activities to include post-discharge assessment, medication reconciliation/review, and ensuring member has access to follow up care. Benefits - Current work environment is remote, however, some state exclusions apply. - Must have access to a reliable and secured internet connection source. - Work environment must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy. - This position will also be required to use reasonable and necessary safeguards to protect GlobalHealth records from unauthorized access, disclosure or damage and will adhere to all GlobalHealth privacy and security policies. Company Description This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Job DetailsJob Location: Any Location Remote US - Oklahoma City, OK 73102Position Type: Full TimeEducation Level: High School or EquivalentTravel Percentage: NoneJob Shift: DayJob Category: NurseWHO WE ARE: GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning. WHO YOU ARE: This position, under the direction of the Supervisor, Care Management, performs and manages all aspects of care management to improve the long-term wellness of members, becoming an advocate for our members through coordination of care. ESSENTIAL JOB FUNCTIONS: Conducts telephonic case management for complex, high-risk members to include identification and assessment of needs, planning and coordination of care, and monitoring outcomes in accordance with GlobalHealth and the departments policies and procedures. Coordinates with providers when applicable to ensure holistic, healthy, beneficial outcomes. Communicates with respect to family culture, ethnic origin, race, language, gender, age, religion, socioeconomic status, sexual orientation, mental and/or physical challenges. Through interdepartmental communication, network communication, and member outreach the Case Manager remains aware of patient needs and changes in condition, providing patient advocacy, support, assessing and ensuring quality care, and providing crisis intervention. Coordination of services for members, including community resources and collaboration with other members of the care team. Educate members and their caregivers on conditions and self-management techniques. Initiate and participate in all elements of the SNP MOC, including completing HRA, creating ICP, and initiating ICT. Complete TOC activities to include post-discharge assessment, medication reconciliation/review, and ensuring member has access to follow up care. QualificationsEDUCATION AND EXPERIENCE: Active Registered Nurse license in the state of Oklahoma required Active multi-state RN license is preferred Previous experience in managed care/utilization management preferred KNOWLEDGE, SKILLS AND ABILITIES: Knowledge of current nursing processes, techniques, and established standards, including disease management, medications, and community resources. Strong attention to detail and good organization and time management skills, including ability to multi-task, learn new skills and reach set goals. Must be able to communicate, both orally and in writing, clearly and effectively Knowledge of Microsoft software programs including Word, Excel, and PowerPoint. Proven ability to work independently or as a member of a team. WORK ENVIRONMENT: Work is normally performed in a professional setting. Work involves standing and walking for brief periods of time, but most duties are performed from a seated position. Work may include occasional pushing and/or pulling, lifting, and carrying objects weighing up to 20 pounds. Work requires normal vision and hearing as might be required in typical conversational use along with finger dexterity and eye-hand coordination to operate a computer keyboard at a moderate skill level. TRAVEL: N/A SUPERVISORY RESPONSIBILITY: N/A OTHER DUTIES: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Job DetailsJob Location: Any Location Remote US - Oklahoma City, OK 73102Position Type: Full TimeEducation Level: High School or EquivalentTravel Percentage: NoneJob Shift: DayJob Category: NurseWHO WE ARE: GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning. WHO YOU ARE: This position, under the direction of the Supervisor, Care Management, performs and manages all aspects of care management to improve the long-term wellness of members, becoming an advocate for our members through coordination of care. ESSENTIAL JOB FUNCTIONS: Conducts telephonic case management for complex, high-risk members to include identification and assessment of needs, planning and coordination of care, and monitoring outcomes in accordance with GlobalHealth and the departments policies and procedures. Coordinates with providers when applicable to ensure holistic, healthy, beneficial outcomes. Communicates with respect to family culture, ethnic origin, race, language, gender, age, religion, socioeconomic status, sexual orientation, mental and/or physical challenges. Through interdepartmental communication, network communication, and member outreach the Case Manager remains aware of patient needs and changes in condition, providing patient advocacy, support, assessing and ensuring quality care, and providing crisis intervention. Coordination of services for members, including community resources and collaboration with other members of the care team. Educate members and their caregivers on conditions and self-management techniques. Initiate and participate in all elements of the SNP MOC, including completing HRA, creating ICP, and initiating ICT. Complete TOC activities to include post-discharge assessment, medication reconciliation/review, and ensuring member has access to follow up care. QualificationsEDUCATION AND EXPERIENCE: Active Registered Nurse license in the state of Oklahoma required Active multi-state RN license is preferred Previous experience in managed care/utilization management preferred KNOWLEDGE, SKILLS AND ABILITIES: Knowledge of current nursing processes, techniques, and established standards, including disease management, medications, and community resources. Strong attention to detail and good organization and time management skills, including ability to multi-task, learn new skills and reach set goals. Must be able to communicate, both orally and in writing, clearly and effectively Knowledge of Microsoft software programs including Word, Excel, and PowerPoint. Proven ability to work independently or as a member of a team. WORK ENVIRONMENT: Work is normally performed in a professional setting. Work involves standing and walking for brief periods of time, but most duties are performed from a seated position. Work may include occasional pushing and/or pulling, lifting, and carrying objects weighing up to 20 pounds. Work requires normal vision and hearing as might be required in typical conversational use along with finger dexterity and eye-hand coordination to operate a computer keyboard at a moderate skill level. TRAVEL: N/A SUPERVISORY RESPONSIBILITY: N/A OTHER DUTIES: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Job DetailsJob Location: Any Location Remote US - Oklahoma City, OK 73102Position Type: Full TimeTravel Percentage: OccasionalJob Shift: DayWHO WE ARE: GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning. WHO YOU ARE: This position performs utilization management review. This position determines appropriateness of services, medical necessity, and location of services required to encourage effective, high-quality care and cost-efficient outcomes through. This position requires excellent verbal and written communication, organization and time management skills. ESSENTIAL JOB FUNCTIONS: Reviews preservice requests, appropriateness of services, and ensure timely determination Communicates with customers, both internal and external, regarding status of referral/referral process. Utilizes NCDs, LCDs, MCG, and additional guidelines to assist in determining coverage of the request. Maintains current knowledge of managed care issues (benefits, contracted providers, health plan guidelines, MCG, NCD, LCD and community standards of practice and regulatory developments, and new and experimental procedures). Collaboration with internal team to support member needs, including but not limited to discharge planning, provider relations, and care management. Adheres to company and department policies and procedures. Performs other duties as assigned Qualifications EDUCATION AND EXPERIENCE: Current active LPN license in Oklahoma/Texas or compact Experience in managed care/utilization management preferred Minimum of 3-5 years of clinical experience required KNOWLEDGE, SKILLS AND ABILITIES: Working knowledge of ICD-10/CPT codes preferred Working knowledge of Microsoft software programs Excellent organizational skills Strong communication skills Proven ability to work independently and as a member of a team WORK ENVIRONMENT: Current work environment is remote; however, some state exclusions apply. Must have access to a reliable and secured internet connection source. Work environment must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy. This position will also be required to use reasonable and necessary safeguards to protect GlobalHealth records from unauthorized access, disclosure or damage and will adhere to all GlobalHealth privacy and security policies. TRAVEL: May require limited travel for offsite meetings or training SUPERVISORY RESPONSIBILITY: This position has no supervisory responsibility OTHER DUTIES: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Job DetailsJob Location: Any Location Remote US - Oklahoma City, OK 73102Position Type: Full TimeTravel Percentage: OccasionalJob Shift: DayWHO WE ARE: GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning. WHO YOU ARE: This position performs utilization management review. This position determines appropriateness of services, medical necessity, and location of services required to encourage effective, high-quality care and cost-efficient outcomes through. This position requires excellent verbal and written communication, organization and time management skills. ESSENTIAL JOB FUNCTIONS: Reviews preservice requests, appropriateness of services, and ensure timely determination Communicates with customers, both internal and external, regarding status of referral/referral process. Utilizes NCDs, LCDs, MCG, and additional guidelines to assist in determining coverage of the request. Maintains current knowledge of managed care issues (benefits, contracted providers, health plan guidelines, MCG, NCD, LCD and community standards of practice and regulatory developments, and new and experimental procedures). Collaboration with internal team to support member needs, including but not limited to discharge planning, provider relations, and care management. Adheres to company and department policies and procedures. Performs other duties as assigned Qualifications EDUCATION AND EXPERIENCE: Current active LPN license in Oklahoma/Texas or compact Experience in managed care/utilization management preferred Minimum of 3-5 years of clinical experience required KNOWLEDGE, SKILLS AND ABILITIES: Working knowledge of ICD-10/CPT codes preferred Working knowledge of Microsoft software programs Excellent organizational skills Strong communication skills Proven ability to work independently and as a member of a team WORK ENVIRONMENT: Current work environment is remote; however, some state exclusions apply. Must have access to a reliable and secured internet connection source. Work environment must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy. This position will also be required to use reasonable and necessary safeguards to protect GlobalHealth records from unauthorized access, disclosure or damage and will adhere to all GlobalHealth privacy and security policies. TRAVEL: May require limited travel for offsite meetings or training SUPERVISORY RESPONSIBILITY: This position has no supervisory responsibility OTHER DUTIES: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Job DetailsJob Location: Any Location Remote US - Oklahoma City, OK 73102Position Type: Full TimeEducation Level: High School or EquivalentTravel Percentage: NoneJob Shift: DayJob Category: NurseWHO WE ARE: GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning. WHO YOU ARE: This position, under the direction of the Supervisor, Care Management, performs and manages all aspects of care management to improve the long-term wellness of members, becoming an advocate for our members through coordination of care. ESSENTIAL JOB FUNCTIONS: Conducts telephonic case management for complex, high-risk members to include identification and assessment of needs, planning and coordination of care, and monitoring outcomes in accordance with GlobalHealth and the departments policies and procedures. Coordinates with providers when applicable to ensure holistic, healthy, beneficial outcomes. Communicates with respect to family culture, ethnic origin, race, language, gender, age, religion, socioeconomic status, sexual orientation, mental and/or physical challenges. Through interdepartmental communication, network communication, and member outreach the Case Manager remains aware of patient needs and changes in condition, providing patient advocacy, support, assessing and ensuring quality care, and providing crisis intervention. Coordination of services for members, including community resources and collaboration with other members of the care team. Educate members and their caregivers on conditions and self-management techniques. Initiate and participate in all elements of the SNP MOC, including completing HRA, creating ICP, and initiating ICT. Complete TOC activities to include post-discharge assessment, medication reconciliation/review, and ensuring member has access to follow up care. QualificationsEDUCATION AND EXPERIENCE: Active Registered Nurse license in the state of Oklahoma required Active multi-state RN license is preferred Previous experience in managed care/utilization management preferred KNOWLEDGE, SKILLS AND ABILITIES: Knowledge of current nursing processes, techniques, and established standards, including disease management, medications, and community resources. Strong attention to detail and good organization and time management skills, including ability to multi-task, learn new skills and reach set goals. Must be able to communicate, both orally and in writing, clearly and effectively Knowledge of Microsoft software programs including Word, Excel, and PowerPoint. Proven ability to work independently or as a member of a team. WORK ENVIRONMENT: Current work environment is remote; however, some state exclusions apply. Must have access to a reliable and secured internet connection source. Work environment must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy. This position will also be required to use reasonable and necessary safeguards to protect GlobalHealth records from unauthorized access, disclosure or damage and will adhere to all GlobalHealth privacy and security policies. TRAVEL: N/A SUPERVISORY RESPONSIBILITY: N/A OTHER DUTIES: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.