- MercyCare, Janesville, WI
- 80 hours/2 weeks, Monday – Friday, Day shift
Experience a rewarding and fulfilling career with Mercyhealth. Mercyhealth is committed to offering our partners a best place to work. Our unique workplace Culture of Excellence is built upon:
- Employee engagement, empowerment and growth
- Teamwork toward our common goal – providing exceptional health care services with a passion for making lives better
- An atmosphere of caring and quality that cascades throughout the organization
Essential duties and Responsibilities
- Function as the Medicaid HMO Advocate
- Analyze and recommend policy and procedural changes to Mercyhealth functions including those needed to ensure and/or improve member cultural sensitivity issues, access to medical care and quality of medical care.
- Perform member outreach to assist in choosing a primary care provider, explaining services, and respond to member inquiries.
- Facilitates the interpretation of fee schedules, contract language, benefit determinations, and access issues for providers, members, and MercyCare partners.
- Perform Medicaid encounter data reconciliation referencing Medicaid requirements and identifying operational improvements with Directors to ensure accurate payment of claims, recoupment of dollars paid in error, and reimbursement from the State.
- Participate in working with the Wisconsin Department of Health Services Managed Care staff on issues of access to medical care, quality of medical care, member enrollment and approval of required informing materials to be distributed to members.
- Serve on MercyCare’s grievance committee and monitor formal and informal grievances for purposes of identification of problem areas of access and care delivery.
- Act as the primary contact for community-based organizations (e.g., county agencies, non-profit agencies) and member advocacy groups on an ongoing basis to acquire knowledge of the issues of members and work to resolve such issues.
- Prepare and deliver education materials for Mercyhealth partners including physicians regarding the administration of the Medicaid program contract.
- Must understand Medicaid contract requirements and attend required external meetings (e.g. monthly Advocate meetings).
- Obtain, analyze, prepare, and deliver requested plan information and member records for governmental agencies (e.g. Office of Inspector General requests, Wisconsin Department of Health Services (DHS) birth cost reports, DHS Insurance Verification, etc.)
- Ability to assign projects to others.
Education and Experience
A minimum of a Bachelor’s degree (BA. or BS.), Social Work, Nursing, or other health-care related degree; and/or two to four years healthcare experience.
Direct experience with the WI Medicaid program is preferred.
Special Physical Demands
The Special Physical Demands are considered Essential Job Functions of the position with or without reasonable accommodations.
While performing the duties of this job, the partner is frequently required to sit; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The partner is occasionally required to stand; walk; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required by this job include close vision, distance vision, and the ability to adjust focus.