- Samaritan Health Plans (SHP) provides health insurance options to Samaritan employees, community employers, and Medicare and Medicaid members. SHP operates a portfolio of health plan products under several different legal structures: InterCommunityHealth Plans, Inc. (IHN) is designated as a regional Coordinated Care Organization (CCO) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group PPO and EPO plans; SHP is also the third-party administrator for Samaritan Health Services’ self-funded employee health benefit plan.
As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services’ mission of Building Healthier Communities Together.
This is a remote position in which we are able to employ in the following states: Alabama, Alaska, Arizona, Arkansas, Connecticut, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, or Wisconsin
Occasionally
- JOB SUMMARY/PURPOSE
- Responsible for development of processes to comply with delegation standards and audit requirements. Collaborates closely with CSD and provider network management individuals to implement requirements for delegated services. Responsibilities include pre-delegation audits, coordination with delegated entities, quarterly audits of the delegate, and reports relating to delegated activities for committee review. Leads, supports, and aligns efforts by collaborating with operational teams to identify, implement and monitor policies and processes to ensure compliance with delegation standards.
- EXPERIENCE/EDUCATION/QUALIFICATIONS
- Bachelor’s Degree in a related field or equivalent experience required.
- Three (3) years directly related experience in a managed care/health plan/health insurance setting required.
- Leadership experience required.
- Experience in management principles, practices, policies, procedures and regulations as they relate to assigned program(s) required.
- Experience and/or training in computer applications, including word processing and spreadsheet software, required.
- KNOWLEDGE/SKILLS/ABILITIES
- Has principal authority and responsibility for the development, implementation, oversight, and evaluation of all aspects of delegation program and services
- Develops and updates audit tools, reports, criteria and metrics to monitor performance.
- Provides oversight and direction for regulatory requirements including reporting.
- Oversees and monitors the development and implementation of all aspects of the delegation programs including, but not limited to the Delegation Oversight Program, Internal Audit Program, and the Policy/Procedure Program.
- Collaborates with appropriate leadership for each line of business to provide guidance and assist with monitoring for compliance with applicable Federal and State rules and regulations across all lines of business.
- Coordinates resources to ensure ongoing effectiveness of the delegation and regulatory oversight program.
- Coordinates with department leadership as necessary and applicable in the execution of the Delegation Oversight Program, Internal Audit Program, and the Policy/Procedure Program.
- Leadership - Inspires, motivates, and guides others toward accomplishing goals. Achieves desired results through effective people management.
- Conflict resolution - Influences others to build consensus and gain cooperation. Proactively resolves conflicts in a positive and constructive manner.
- Critical thinking – Identifies complex problems. Involves key parties, gathers pertinent data and considers various options in decision making process. Develops, evaluates and implements effective solutions.
- Communication and team building – Lead effectively with excellent verbal and written communication. Delegates and initiates/manage cross-functional teams and multi-disciplinary projects.
- PHYSICAL DEMANDS
- Rarely (1 - 10% of the time)
(11 - 33% of the time)
Frequently
(34 - 66% of the time)
Continually
(67 – 100% of the time)
CLIMB - STAIRS
LIFT (Floor to Waist: 0"-36") 0 - 20 Lbs
LIFT (Knee to chest: 24"-54") 0 – 20 Lbs
LIFT (Waist to Eye: up to 54") 0 - 20 Lbs
CARRY 1-handed, 0 - 20 pounds
BEND FORWARD at waist
KNEEL (on knees)
STAND
WALK – LEVEL SURFACE
ROTATE TRUNK Standing
REACH - Upward
PUSH (0 - 20 pounds force)
PULL (0 - 20 pounds force)
SIT
CARRY 2-handed, 0 - 20 pounds
ROTATE TRUNK Sitting
REACH - Forward
MANUAL DEXTERITY Hands/wrists
FINGER DEXTERITY
PINCH Fingers
GRASP Hand/Fist
PI256157902
