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Serve as a liaison between the plan, claims, providers and various departments to effectively identify and resolve claims issues Audit check run and send claims to the claims department for corrections Identify any system changes and work notify the Plan CIA Manager to ensure its implementation Collaborate with the claims department to price pended claims correctly Document, track and resolve all
Posted 6 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 9 days ago
Direct medical management program including utilization management, case management, quality improvement and credentialing in accordance with the mission, philosophy, and objectives of plan and in conjunction with Corporate goals and objectives. Develop department objectives and organize activities to achieve objectives. Evaluate and implement changes to medical service functions and performance i
Posted 11 days ago
Direct and coordinate the medical management, quality improvement and credentialing functions for the assigned business unit based on, and in support of the strategic plan, establishing the strategic vision and attendant policies and procedures. Serves as clinical advisor to and educator of medical management staff making sure correct clinical judgment is applied to all medical management determin
Posted 12 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 12 days ago
Responsible for members gaining access to needed services through coordination and integration of medical and long term care services for the purpose of orientation, care plan development, assessment, and care coordination. Complete assessments with members, caregivers, or providers to obtain information regarding client status, support system, and need for services for care plan development Monit
Posted 13 days ago
Perform collaborative duties for the development and implementation of all Coordinated Care programs (OB/NICU, Asthma, Diabetes, ER, General/Catastrophic); Provide support and supervision to ensure quality and continuity of services delivered to Members, Providers and staff. Develop and oversee aspects of coordinated care program activities Develop and implement management software and reporting m
Posted 16 days ago
Assist in activities related to the medical and psychosocial aspects of utilization and coordinated care. Initiate authorization requests for output or input services in keeping with the prior authorization list. Research claims inquiry specific to the department and responsibility. Perform tasks necessary to promote member compliance such as verifying appointments, obtaining lab results. Assess a
Posted 16 days ago
Lead analytical data needs for all HP's and business units. Initiate and lead company wide data processes improvements Lead cross functional activities related to large scale analytic projects to deliver on schedule, within budget and with superior quality Develop and lead activities to accomplish overall strategic department goals and lead the communication of these goals to stakeholders at all l
Posted 16 days ago
Perform onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Direc
Posted 16 days ago
Assist in activities related to the medical and psychosocial aspects of utilization and coordinated care. Initiate authorization requests for output or input services in keeping with the prior authorization list. Research claims inquiry specific to the department and responsibility. Perform tasks necessary to promote member compliance such as verifying appointments, obtaining lab results. Assess a
Posted 16 days ago
Assist in activities related to the medical and psychosocial aspects of utilization and coordinated care. Initiate authorization requests for output or input services in keeping with the prior authorization list. Research claims inquiry specific to the department and responsibility. Perform tasks necessary to promote member compliance such as verifying appointments, obtaining lab results. Assess a
Posted 16 days ago
Accountable for aligning human resources strategy with business strategy. Drives the HR agenda, partnering closely with Centers of Expertise (COEs), HR Operations and business unit leaders to effectively and efficiently deliver HR processes and initiatives for a business unit. Responsible for coaching the front line people managers and partner with them to resolve employee related matters Develop
Posted 17 days ago
Perform duties to authorize and review utilization of mental health and substance abuse services provided in inpatient, outpatient and intermediate care settings, provide and/or review intakes and initial evaluations, brief focused treatment interventions, monitor quality of care, collect and analyze utilization and cost of care data, assist with discharge planning, arrange transportation; provide
Posted 18 days ago
Perform duties to assist in activities related to the medical and psychosocial aspects of utilization and coordinated care. Initiate authorization requests for output or input services in keeping with the prior authorization list. Maintain integrity of PHI. Maintain working relationships with other departments. Research claims inquiry specific to the department and responsibility. Attend ongoing t
Posted 18 days ago
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