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LHP Update Adds to JD Breakdown List @ 10/20/13

Adheres to policies, procedures and regulations to ensure compliance and patient safety

Analyzes data (DMM) HSM

Analyzes data (MMM)

Approves purchases of furniture and equipment through Purchasing Department and CER

process (FM)

Assess the various enrollment programs regularly, to determine if the programs are

meeting the intended goals (EEM)

Assists Department Head to develop policies, procedures, strategies and goals that

support Department/Corporation direction (MEM)

Assists Department Head with the development of the strategic planning for the

organization (MEM)

Assists in the development of new recruitment training (SM)

Assists management with documentation required for accreditation agency audits as

needed (MMM)

Attends professional and/or departmental meetings (LUM)

Brainstorms on innovative ideas (LUM)

Builds trust/credibility with customers by demonstrating commitment to achieving

mutual goals (EEM)

Collaborate with Sales to develop rate action for new and existing groups that support the

customer expectation, as well as, corporate goals (LUM)

Collaborates with a wide variety of functional areas such as sales, underwriting,

marketing, health services, and operations to develop and provide product definitions

responsive to customer needs and market opportunities (PSM)

Collaborates with headquarters on special facilities related projects (FM)

Collaboratively works with delegated vendors to improve quality of care and outcomes

(MMM)

Communicates resolutions (LUM)

Communicates resolutions(PMM)

Completes required monthly, quarterly reports accurately and in a timely manner (MMM)

Conducts market research (PSM)

Conducts marketing analysis to develop product definitions (PSM)

Conducts post-event de-briefings to ensure a continuous process improvement effort is

undertaken (EEM)

Conducts presentations (LUM)

Conducts presentations (PMM)

Coordinates marketing, sales, operation, and financial plans for product line(s) (PSM)

Coordinates projects, reports and meetings (RAM)

Coordinates a variety of meetings (PDM)

Coordinates all training programs (TM)

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Coordinates annual Provider Seminars in conjunction with other key Plan departments

Coordinates as required with the Network Operations Director, and any other key

management/departments (PSM)

Coordinates daily staff assignments for designated department to include hiring, firing,

disciplinary actions, evaluations and training (RAM)

Coordinates in-house moves, adds and changes including system furniture

reconfigurations, renovations and new construction (FM)

Coordinates on-site and off-site storage activity (FM)

Coordinates pricing requirements for non-standard benefits through the Actuarial support

(LUM)

Coordinates professional and/or departmental meetings (LUM)

Coordinates several projects at the same time to ensure a seamless transition from one

event to another (EEM)

Coordinates technical product development, estimates of potential sales profits, and

release to production (PSM)

Coordinates the reporting requirements of the state (MPM)

Creates an environment conducive to providing service excellence (EEM)

Demonstrates a high level of attention to detail and follow through (EEM)

Demonstrates knowledge of service of provider networks (PSM)

Demonstrates knowledge of the principles of growth and development over the

appropriate age span of the unit's patients (EEM)

Demonstrates proficient knowledge of healthcare underwriting and managed care

products (LUM)

Demonstrates proficient knowledge of healthcare underwriting and managed care

products (PMM)

Designs all training programs (TM)

Designs and changes employee services programs in order to enhance

employee/organization relationships and better serve both the employee and the

organization, based on these assessments and de-briefings (EEM)

Develop renewal and new case presentations for customers that explain rate actions and

expected outcomes (LUM)

Develops (as required) the Provider Reference Guide, Provider Newsletters, annual

Provider Satisfaction Survey and any provider communications in collaboration with the

Network Operations Director, other internal staff and departments to ensure appropriate

updates are made and distributed to the provider network timely (PSM)

Develops a prioritized list of customer and market requirements for product line(s) (PSM)

Develops a variety of analytical and statistical reports to assist with departmental

forecasting (MEM)

Develops a variety of analytical and statistical reports to assist with departmental

forecasting

Develops all aspects of the underwriting process and guidelines to obtain profitability and

membership objectives (USM)

Develops ASO funding rate presentations(LUM)

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Develops business relationships with a variety other departments on product and service

development (PSM)

Develops comprehensive plans to satisfy facilities needs using sound financial judgment

(FM)

Develops marketing, sales, operation, and financial plans for product line(s) (PSM)

Develops policies, processes, strategies and goals that support Department/Corporation

direction Ensures compliance with all state, federal and other regulatory entities as

required (PSM)

Develops processes and ensure department compliance with all regulatory entities,

including NCQA, DOI, HSD, NMMRA, HEDIS (PSM)

Develops rate structures that offer the ability to enhance market share and maintain

profitability according to budget (direct through team responsibility) (LUM)

Develops routine reporting packages, ensuring consistency in all deliverables to our

clients (LUM)

Develops staff (LUM)

Develops standard operating procedures as appropriate to ensure efficiency of department

processes and compliance with developed policy and procedures (PSM)

Devises process improvements based on findings (MMM)

Distributes sales leads for respective Sales Team based on monthly sales performance

(SM)

Emphasizes continuous quality improvement (LUM)

Ensure the production of all required regulatory reports are timely, accurate, and are

produced as needed to ensure department and Health Plan compliance with all regulatory

entities. Such reports include but are not limited to HSD reporting, Geo Access and

Availability reporting, NCQA reporting, and DOI reporting (PSM)

Ensures compliance with city, state and federal codes and regulations (FM)

Ensures compliance with State and Federal regulations through daily supervision of staff,

monitoring individual sales performance and activities (SM)

Ensures quality and customer satisfaction by conducting and reviewing call audits (CCM)

Evaluates all training programs (TM)

Evaluating rate structures that offer the ability to enhance market share and maintain

profitability according to budget (LUM)

Forecasts expected outcomes (LUM)

Generates a variety of reports, records and files (PDM)

Generates data (MMM)

Identifies areas of improvement and resource requirements (PMM)

Identifies issues or abnormalities not in the normal course of business (LUM)

Identifies market trends (PSM)

Identifies quality consumer/participant care models and competencies related to case

management (TPM)

Implementation of safety management procedures (FM)

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Implements all aspects of the underwriting process and guidelines to obtain profitability

and membership objectives (USM)

Implements approved changes (MEM)

Implements compliance regarding the Commercial, Medicare and Medicaid Lines of

business (PEM)

Implements departmental policies and procedures (PEM)

Implements policies and procedures that will enhance the efficiency and compliance of

program and/or organization (MPM)

Implements process improvements based on findings (MMM)

Implements quality consumer/participant care models and competencies related to case

management (TPM)

Implementing rate structures that offer the ability to enhance market share and maintain

profitability according to budget (LUM)

Initiates timely performance feedback (LUM)

Initiating effective channels of communication with providers and related office staff

Interacts with supervisors, peers, other departments and all customer groups

demonstrating our commitment to “service” (MEM)

Maintaining effective channels of communication with providers and related office staff

(PSM)

Maintains (as required) the Provider Reference Guide, Provider Newsletters, annual

Provider Satisfaction Survey and any provider communications in collaboration with the

Network Operations Director, other internal staff and departments to ensure appropriate

updates are made and distributed to the provider network timely (PSM)

Maintains a prioritized list of customer and market requirements for product line(s)

(PSM)

Maintains a variety of reports, records and files to ensure compliance (CCM)

Maintains a variety of training material, reports, records, and files (TM)

Maintains business relationships with a variety other departments on product and service

development (PSM)

Maintains internal and regulatory Policies and Procedures (RAM)

Maintains monthly sales reports as required (SM)

Maintains ongoing sales training and education (SM)

Maintains projects, reports and meetings(RAM)

Maintains statistical data in an application database in accordance with internal and

regulatory requirements (RAM)

Maintains statistical data, trending and data reporting of case to include but not limited to

Mi Via/PCO (TPM)

Maintains statistical reports and records pertaining to operations and activities (PEM)

Makes recommendations regarding areas of improvement (CCM)

Manages all operational functions within budget (LUM)

Manages all State/CMS and other regulatory compliance standards (TPM)

Manages daily operations and activities for assigned department and staff (TPM)

Manages multiple projects, timelines and deliverable

using____________________________ (PMM)

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Manages overall clinical and non-clinical medical services related to medical utilization

management operations, case management and concurrent review activities (HSM)

Manages overall clinical and non-clinical medical services related to medical utilization

management operations, case management and concurrent review activities (MMM)

Manages the daily operations of Provider Servicing to ensure strategic goals and

objectives are being achieved and remain compliant with all regulatory entities (PSM)

Manages the planning and evaluation of the program/project for assigned area to ensure

compliance (MPM)

Manages the reporting requirements of the state (MPM)

Meets deadlines (LUM)

Meets deadlines for healthcare underwriting and managed care products (PMM)

Monitoring of contracts for maintenance and repair of facilities, furniture and equipment

(FM)

Monitors a variety of analytical and statistical reports to assist with departmental

forecasting (MEM)

Monitors a variety of analytical and statistical reports to assist with departmental

forecasting

Monitors a variety of analytics (LUM)

Monitors capital and expense budgets (FM)

Monitors compliance regarding the Commercial, Medicare and Medicaid Lines of

business (PEM)

Monitors overall clinical and non-clinical medical services related to medical utilization

management operations, case management and concurrent review activities (HSM)

Monitors overall clinical and non-clinical medical services related to medical utilization

management operations, case management and concurrent review activities (MMM)

Monitors strategic activities to ensure objectives are achieved (PSM)

Monitors strategic plan activities to ensure objectives are achieved (PDM)

Negotiation of contracts for maintenance and repair of facilities, furniture and equipment

(FM)

Orders purchases of furniture and equipment through Purchasing Department and CER

process (FM)

Oversees all State/CMS and other regulatory compliance standards (TPM)

Oversees daily staff assignments for designated department to include hiring, firing,

disciplinary actions, evaluations and training (RAM)

Oversees the daily operations of Provider Servicing to ensure strategic goals and

objectives are being achieved and remain compliant with all regulatory entities (PSM)

Oversees the development of strategic plan activities to ensure objectives are achieved

(PDM)

Oversees the development of strategic plan activities to ensure objectives are achieved

(PSM)

Oversees the planning and evaluation of the program/project for assigned area to ensure

compliance (MPM)

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Participates in developing policies and procedures that will enhance the efficiency and

compliance of program and/or organization (MPM)

Participates in development and implementation of plan to provide state-of-the-art

services enrollment process (EEM)

Participates in key sales situations for the product (PSM)

Participates in new initiatives (LUM)

Participates in pharmacy quality reviews and regulatory standards (PEM)

Participates in professional and/or departmental meetings (LUM)

Participates in the development and implementation of departmental policies and

procedures (PEM)

Participates in the development of the strategic planning for the organization

Participates in the strategic planning process for meeting growth and profitability goals

(LUM)

Performs duties as assigned by Director, Pharmacy Services (PEM)

Performs other duties as assigned or requested (LUM)

Performs other functions as necessary (LUM)

Plans the development of strategic plan activities to ensure objectives are achieved

(PDM)

Plans the development of strategic plan activities to ensure objectives are achieved (PSM)

Prepares a variety of training material, reports, records, and files(TM)

Prepares capital and expense budgets (FM)

Prepares product development objectives and schedules for all phases of product

development and introduction to market using a defined product lifecycle management

model (PSM)

Presents to internal and external customers (LUM)

Produces a variety of reports, records and files to ensure compliance (CCM)

Produces competitive analysis materials comparing product with its key competitors

(PSM)

Produces comprehensive sales reporting and analysis structures to include metrics which

measures leads and sales effectiveness (SM)

Produces monthly sales reports as required (SM)

Produces statistical reports (DMM) HSM, PEM

Provides appropriate support both internally and externally as required(RAM)

Provides direct consumer/participant care management services (TPM)

Provides feedback regarding areas of improvement (CCM)

Provides financial and technical justification for product selection and definition (PSM)

Provides technical expertise to other departments in support of product development as

well as ongoing product sales and support (PSM)

Provides training to other departments in support of product development as well as

ongoing product sales and support (PSM)

Recommends areas of improvement (DMM) HSM

Recommends changes to policies and procedures when necessary

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Recruits staff (LUM)

Trains staff (LUM)

Reports on data (MMM)

Resolves customer problems (LUM)

Resolves issues or abnormalities not in the normal course of business (LUM)

Responds to customer complaints (CCM)

Responsibility includes quick and courteous interaction with Plan providers (PSM)

Responsibility includes quick and courteous response with Plan providers (PSM)

Responsible for all decision making and problem resolution needed to carry out all

enrollment events and programs (EEM)

Responsible for conducting Grand Rounds with supporting report on a bi-weekly basis

(MMM)

Responsible for employee Ergonomics assessments and evaluation (FM)

Responsible for managing day to day operations and UW Staff (USM)

Responsible for managing the daily operations within assigned area (PDM)

Responsible for operational and administrative management of the Medicaid program for

assigned area (MPM)

Responsible for product development regarding the strategic, operational, fiscal and

objectives of the department (PDM)

Responsible for product development regarding the strategic, operational, fiscal and

objectives of the department (PSM)

Responsible for product direction regarding the strategic, operational, fiscal and

objectives of the department (PDM)

Responsible for product direction regarding the strategic, operational, fiscal and

objectives of the department (PSM)

Responsible for resolving facilities-related issues including electrical, mechanical,

security, janitorial and parking (FM)

Responsible for supporting the Health Plan and Network Operations by providing

consistent and accurate resolution to providers’ inquiries (PSM)

Responsible for the production schedule

Responsible for turnaround service level agreement (LUM)

Reviews and approves invoices pertaining to general office expenses (FM)

Reviews drawings, specifications and estimates (FM)

Reviews routine reporting packages, ensuring consistency in all deliverables to our

clients (LUM)

Schedules assigned sales team company sponsored seminars and sales activities (SM)

Schedules ongoing sales training and education (SM)

Seeks customer feedback to align business strategy with priority customer needs(EEM)

Serves as a departmental liaison (CMM, DMM, MPM, RAM, PDM, PSM,MTR)

Serves as departmental liaison (PSM)

Supervises all training programs (TM)

Supervises personnel for security, mail distribution, shipping/receiving, supplies,

messenger/courier, reception, conference room, kitchen services (FM)

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Supervises priorities and workloads for assigned professionals within the department to

ensure timely and accurate deliverables (MEM)

Supports the acquisition of stop loss fees (LUM)

Takes ownership of assignments, special projects, pilot programs (LUM)

Tracks market trends (PSM)

Tracks processes and ensure department compliance with all regulatory entities,

including NCQA, DOI, HSD, NMMRA, HEDIS (PSM)

Troubleshoots issues or abnormalities not in the normal course of business (LUM)

Understands Lovelace Health Plan business requirements (FM)

Understands the benefit plans and associated rating methodologies (LUM)

Works with various team members to develop communication plans and materials

(PMM)