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Maintain accurate databases and reports to monitor network compliance with State requirements Create and maintain multiple databases, including, contract provider network, prior authorization, third party liability, provider set ups and related corrections Oversee the provider termination process including adding and changing new or existing provider records in the medical information system Sched
Posted 3 days ago
Perform duties to act as a liaison between providers, the health plan and Corporate including investigating and resolving provider claims issues. Perform training, orientation and coaching for performance improvement within physician practices. Serve as primary contact for providers serving as a liaison between the provider and the health plan Conduct monthly face to face meetings with the provide
Posted 4 days ago
Provide hands on training to clinical staff in Medical Management on the various aspects of their job functions and responsibilities. Provide an avenue of consistent training among the clinical staff; define expectations of each specific role for accountability and facilitate clinical training for the staff. Develop and conduct clinical educational classes/course Develop, conduct and ensure mainte
Posted 4 days ago
Provide health education and coaching to members tailored to issues identified within treatment and service plans Coordinate with various healthcare providers for diagnostics, ambulatory care, and hospital services Assist members with social determinants of health including access to exercise and healthy food Promote activities focused on the health of a patient and their community, including with
Posted 4 days ago
Utilization Management Specialist Behavioral Health Utilization Management Specialist Behavioral Health (1115115) Ensure all members are receiving the right care, in the right place, at the right time through Utilization Review and Discharge Planning work. Work with hospital staff, community agencies, members and families to coordinate effective and clinically appropriate discharge plans. Promote
Posted 5 days ago
Supervisor, Medical Management (Non Clinical) Supervisor, Medical Management (Non Clinical) (1113875) Position Purpose Supervise the day to day operations of the medical review unit Oversee changes to medical review unit functions and performance in relation to company mission, philosophy objectives and policies Assist senior management with budgets and forecast for strategic planning and key init
Posted 5 days ago
Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests. Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with
Posted 5 days ago
Analyze and resolve verbal and written claims and authorization appeals from providers and pursue resolution of formal grievances from members. Gather, analyze and report verbal and written member and provider complaints, grievances and appeals Prepare response letters for member and provider complaints, grievances and appeals Maintain files on individual appeals and grievances May coordinate the
Posted 5 days ago
Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosi
Posted 5 days ago
Provide health education and coaching to members tailored to issues identified within treatment and service plans Coordinate with various healthcare providers for diagnostics, ambulatory care, and hospital services Assist members with social determinants of health including access to exercise and healthy food Promote activities focused on the health of a patient and their community, including with
Posted 5 days ago
Perform various analysis and interpretation to link business needs and objectives for assigned function Support business initiatives through data analysis, identification of implementation barriers and user acceptance testing of new systems Identify and analyze user requirements, procedures, and problems to improve existing processes Perform detailed analysis on assigned projects, recommend potent
Posted 5 days ago
Authorize and/or review utilization of mental health and substance abuse services provided in inpatient and intermediate care settings. Assure appropriate levels of care and medical necessity in a manner that supports the recovery process Identify placement settings that offer the lowest level of restriction and greatest level of autonomy for the members based upon medical necessity Monitor qualit
Posted 5 days ago
Analyze, develop, implement and monitor clinical quality improvement initiatives to achieve healthy outcomes. Perform duties and functions to comply with quality improvement programs according to state requirements. Support Quality Assurance Performance Improvement work plan/initiatives. Schedule and assist with committee and sub committee preparation. Assist in investigation and resolution of mem
Posted 6 days ago
Responsible for the auditing of corporate, health plan, and specialty company staff related to clinical systems entry and/or processes Develop and maintain the audit process and tools related to authorizations, appeals, quality events, and case management in CCMS; interrater reliability related to InterQual; and data entry into the credentialing subsystem Develop and maintain the audit schedule Au
Posted 6 days ago
Perform duties to ensure HEDIS data accuracy and reporting, including investigation, auditing, and improvement opportunities. Assist with quality improvement initiatives in the service and clinical areas. Coordinate, complete, and update management on clinical quality metrics and HEDIS processes and results Establish and maintain an action plan to improve HEDIS scores Implement process to request
Posted 6 days ago
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