Making health care more accessible, understandable, and collaborative.
Explore our career opportunities at https://wvumedicine.wd1.myworkdayjobs.com/PEAK

Peak Health

Browse and apply for open jobs at Peak Health.

manager

Peak Health is a health insurer and health insurance services company headquartered in Morgantown, West Virginia. It is owned by three not-for-profit health care providers: WVU Health System, Marshall Health Network, and Valley Health. Peak Health aims to improve community health outcomes by offering an inclusive, provider-led health plan for residents of West Virginia and surrounding areas. The company is committed to making health care more accessible, understandable, and collaborative, with a focus on reducing costs and administrative fees for patients and employers. Peak Health also offers Medicare Advantage coverage tailored for West Virginia seniors through partnerships with leading health systems.

Making health care more accessible, understandable, and collaborative.
Explore our career opportunities at https://wvumedicine.wd1.myworkdayjobs.com/PEAK  

• Participate in activities related to care management program build, implementation, oversight, and delegation.
• Perform utilization management reviews as needed according to accepted and established criteria, as well as other clinical guidelines and policies.
• Manage and triage member self-referrals to care management programs.
• Assist members in understanding their available medical benefits and connecting them with in-network providers and community resources.
• Identify barriers preventing the member from meeting maximum quality of life.
• Review and Evaluate Health Risk Assessment (HRA) data to help drive development of programs and services geared toward member needs.
• Review and Evaluate member outcomes data and work with other team members on performance improvement opportunities.
• Utilizing NCQA standards in auditing processes of member records as part of care management oversight processes.
• Investigating potential quality of care issues that may affect the quality or safety of the health of members.
• May review medical records and other documentation to ensure quality care.
• Assist in reviewing and updating activities and resources to address member needs.
• Participate in case management and quality committees.
• Assist in reviewing and updating policies and procedures to align with delegated processes.
• Assist in quarterly reporting of delegated case management processes to meet accreditation standards.
• Assist in submission of required documents/policies during application process to accrediting body.

Care Manager, RN

Care Manager RN identifying and connecting high-risk members to resources for optimal care outcomes at Peak Health. Responsible for case management and program implementation.

accounts-payable

• Compiles and processes accounts payable, maintains day to day payment cycle, and provides efficient customer service.
• Verify approval on all payment requests.
• Process payments to contracted providers for claims submitted to and processed by the Claims Operations department.
• Resolves problems associated with payables transactions.
• Reconciles processed work by verifying entries and comparing system reports to balances.
• Provides accurate and effective document preparation and records management relative to the Accounts Payable function in accordance with records retention policies and procedures, and any federal regulations (if applicable).

Accounts Payable Representative

Accounts Payable Rep responsible for processing payments and maintaining financial records for Peak Health. Providing customer service and ensuring compliance with financial procedures.

accounting-manager

• Premium Billing - processes the monthly premium billing cycle for ASO PEPM fees and Medicare Advantage enrollees.
• CRM Responsibilities - Research, resolve and communicate resolution to internal team as well as external vendors for any finance related customer relationship management (CRM) request(s).
• Claims Funding - Communicates weekly claims funding totals for both capitated and non-capitated claims to ASO clients as part of the weekly claims settlement process.
• Claims Settlement Analytics - Provides management with weekly claims settlement analytics and reports.
• Manages vendor information for accuracy relating to address and banking information to ensure payments to vendors are received and/or processed in a timely fashion.
• Compiles and processes accounts payable, maintains day to day payment cycle, and provides efficient customer service.

Insurance Accounting Specialist

Insurance Accounting Specialist providing financial and clerical support within the Accounting/Finance department at Peak Health. Responsible for vendor invoices and provider payments in a hybrid work environment.

• Provides financial, administrative, and clerical support within the Accounting/Finance department
• Responsible for review and processing of vendor invoices, provider payments, and voids and reissues of provider payments
• Processes the monthly premium billing cycle for ASO PEPM fees and Medicare Advantage enrollees
• Reconciles invoices and premium receipt reports to premium billing reports
• Research, resolve, and communicate resolution to internal team as well as external vendors for finance related requests
• Communicates weekly claims funding totals for both capitated and non-capitated claims to clients
• Provides management with weekly claims settlement analytics and reports
• Manages vendor information for accuracy relating to address and banking information
• Compiles and processes accounts payable, maintains payment cycle, and provides customer service
• Verifies approval on all vendor payment requests
• Processes payments to contracted providers for claims submitted
• Resolves problems associated with vendor payables transactions
• Provides accurate document preparation and records management
• Maintains relationships with all areas of the organization
• Protects organization’s value by keeping information confidential
• Updates job knowledge by participating in educational opportunities
• Maintains historical records by imaging and filing documents

Accounting Specialist providing financial, administrative, and clerical support within Finance department. Managing vendor invoices, claims funding, and premium billing.

• Oversees the build and Implement utilization management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews) that are consistent with established industry and regulatory standards/guidance.
• Manages the build and implement all utilization management reviews according to accepted and established criteria, as well as other clinical and regulatory guidelines and policies.
• Assists in the development and implementation of policies and procedures related to the Utilization Management processes.
• Ensures that utilization management interventions are collaborative and focus on maximizing quality member health care outcomes.
• Supervises the facilitation of the Peer-to-Peer Review process, and work with the Medical Directors to continuously improve member and Provider Network services for this process.
• Oversees the education on utilization management that is provided to internal and external stakeholders and partners to continuously improve processes and build network relationships.
• Facilitates a collaborative environment that focuses on collaboration with other members of the medical management team to identify members whose healthcare outcomes may be enhanced by coaching and/or case management interventions.
• Educates team members on the data that is collected within the position and facilitate improvement in outcomes within the team.
• Assists with monitoring performance standards, productivity and ensuring staff coverage to meet the needs of the department.
• Formulates, implements and evaluates educational strategies for staff.
• Maintains a working knowledge of the requirements of regulatory and compliance entities.
• When needed, fill in for staff members to ensure that the operations of the utilization management team are never compromised.
• Commits to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Management.
• Provides clinical, procedural or interpretational assistance.
• Ability to present complex ideas and data to a wide variety of stakeholders from frontline employees to executive c-suite.
• Other duties as assigned or requested.

Manager, Utilization Management, RN

Manager of Utilization Management overseeing department operations and driving effective health utilization at Peak Health. Collaborating with medical directors and ensuring quality outcomes for members.

Making health care more accessible, understandable, and collaborative. Explore our career opportunities at https://wvumedicine.wd1.myworkdayjobs.com/PEAK

Peak Health

About the company

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5 jobs found

Care Manager, RN

Peak Health

Accounts Payable Representative

Peak Health

Insurance Accounting Specialist

Peak Health

Insurance Accounting Specialist

Peak Health

Manager, Utilization Management, RN

Peak Health