Jobs at GlobalHealth Holdings, LLC

Supports Medicare medication adherence and quality initiatives by conducting member and provider outreach, educating members on compliance, tracking calls and statuses, entering data, reviewing prescription records, and monitoring CMS STARS measures. Maintains confidentiality of protected health information under HIPAA and works in a sedentary clerical office environment with no travel or supervisory responsibilities.

Supports healthcare quality initiatives by managing care gaps, conducting member and provider outreach, educating providers on quality measures, entering data, reviewing medical records, tracking referrals, documenting coding, and auditing provider records. Requires knowledge of HEDIS, CAHPS, HOS, Meaningful Use, CMS standards, HIPAA, and electronic health records. The role requires extensive travel during audit season and occasional overnight stays.

Supervises Clinical Quality Specialists and oversees HEDIS-related quality initiatives, provider/member outreach, record audits, data entry, and medical record review to ensure compliance with CMS measures. Maintains PHI confidentiality and coordinates substantial travel for on-site audits.

Provides telephonic case management for complex, high-risk Medicare Advantage members. Assesses needs, coordinates care and community resources, monitors outcomes, communicates with providers and care teams, advocates for members, provides education and crisis support, and completes SNP Model of Care and transition-of-care activities, including health risk assessments, individualized care plans, medication reconciliation, and follow-up coordination.

Lead clinical Appeals & Grievance (A&G) operations, ensuring regulatory and contractual compliance. Manage staffing, scheduling, coaching, performance, and daily workflows. Monitor metrics, handle member escalations, perform first-round quality-of-care reviews, and drive process improvements.