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Provide administrative support for field based care teams Receive and process electronic referral requests for care management services Utilize phone system to respond to and transfer calls to appropriate individuals Ask callers standard questions to understand requests, gather necessary information, and assess urgency Perform member assignment in clinical system and set
Posted Today
Linking members to applicable community resources Complete field visits for high risk, hard to reach members Telephonic outreach to targeted members Keep the member out of the hospital by supporting regular visits to their primary physician Keep member actively engaged with their primary physician Support the member to ensure pick up of their Rx Proactively engage the mem
Posted Today
Design, implement, and own regulatory reporting process across program, including but not limited to the coordination, quality review, and submission of data and reports to state regulator Produce reporting for health plan operations, ad hoc regulator requests and audits Communicate professionally with regulator and field reporting questions, comments, or concerns Project
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Monitor and own current vendor contract status from the initial exploratory phase to internal approval, implementation, go live, and through steady state Partner with appropriate UHG procurement and compliance partners as appropriate for implementation and management of subcontractors and vendors Coordinate ad hoc and ongoing reporting requirements for the health plan and
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Manage and track all escalated provider issue for Home and Community Based Services Lead team of Provider Advocates through claims and provider issue resolutions Act as SME for Home and Community Based Services providers within the health plan Produce reporting for health plan operations related to Home and Community Based Services Advocate for enhancements of physician p
Posted Today
Investigate medium to highly complex cases of fraud, waste and abuse Detect fraudulent activity by members, providers, employees and other parties against the Company Develop and deploy the most effective and efficient investigative strategy for each investigation Maintain accurate, current and thorough case information in the Special Investigations Unit's (SIU's) case tr
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Assess, plan and implement care management interventions that are individualized for each member and directed toward the most appropriate, least restrictive level of care Identify and initiate referrals for both healthcare and community based services; including but not limited to financial, psychosocial, community and state supportive services Develop and implement care
Posted Today
Meet Quality, Productivity and Attendance requirements Making outbound calls to members and provider offices Maintaining accurate documentation Being responsible for any follow up work needed for resolving and closing issues Identifying and resolving anticipated Provider issues to prevent future calls Maintain proficiency in all technical applications (technical skills an
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Monitor, review, research, and process mailbox requests Inventory tracking and reporting Data mining, compiling and preparing reports Mail merges Open, scan and process in coming mail Special Projects as assigned Training material and manual preparation Power point presentations You'll be rewarded and recognized for your performance in an environment that will challenge y
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Making outbound calls and taking inbound calls to assess members' current health status Identifying gaps or barriers in treatment plans Providing patient education to assist with self management Interacting with Medical Directors on challenging cases Coordinating care for members Educating members on disease processes Encouraging members to make healthy lifestyle changes
Posted Today
Assesses member current health status and recommends appropriate level of care based on clinical judgment and protocols Adheres to ethical, legal / regulatory and accreditation standards Assesses members understanding of their condition and identifies potential care and / or provider gaps Provides health education and coaches members on treatment alternatives to assist th
Posted Today
Analyzing and interpreting various forms of health plan cost and utilization data to identify potential areas for lowering financial trends, improving population health and employee productivity, and elevating health care consumerism Delivering "Annual Healthplan Performance Reviews" and participating in other customer meetings as a subject matter expert to present analyt
Posted 1 day ago
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Collaborates with HealthSmart Tribal Business partners to support the Medicare like repricing business by learning an supporting the Clipper based MLR platform Participates in Server migration and tech debt reduction Utilizes a thorough understanding of availa
Posted 1 day ago
Focusing on initial concurrent reviews for higher levels of care, ie Inpatient, Residential and Partial hospital admissions Inpatient admission for psychiatric and chemical dependency patients via telephone Making patient assessments and determining appropriate levels of care Obtaining information from providers on outpatient requests for treatment. Facility Based Care Ad
Posted 1 day ago
Provide skilled nursing care for expectant mothers in the home care environment Travel to provide in home patient care and continuous education to patients and family members Continually assess the mothers' condition to ensure they are safe in the home environment Modify the plan of care, as appropriate, based upon reassessment, change in prescriber orders, the patient's
Posted 1 day ago
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