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Referral Specialist I (1112977) Position Purpose Assist in monitoring utilization of medical services to assure cost effective use of medical resources through processing prior authorizations. Initiate authorization requests for outpatient and inpatient services in accordance with the prior authorization list. Route to appropriate staff when needed. Verify eligibility and benefits Answer phone que
Posted 14 days ago
Program Specialist I Social Work (CENT1110075) Position Purpose Identify special needs members through the completion of health screens and other resources Work with community outreach/member advocates to coordinate member care Educate providers and community resources on program components and available support services Educate members with special needs to foster compliance with program and posi
Posted 18 days ago
Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to emergent/urgent and continued stay reviews. 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
Posted 20 days ago
Update and maintain provider computer records for assigned sites Add, change and terminate new or existing provider records in the medical information system Schedule monthly provider verifications regarding provider enrollment specifications and demographics Oversee Medicare and Medicaid provider directory process including achieving and maintaining compliance with the State and CMS with regards
Posted 22 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 2 months ago
Manage the Member Connections functions, investigate and resolve complex member or provider issues. Ensure timely and quality care to members regarding health benefit questions and issues Develop, implement and maintain production and quality standards for the Member Connections program Identifying high risk members and collaborate with case management to strategize outreach to these high utilizer
Posted 2 months ago
Plans, organizes, monitors, and oversees projects utilizing cross functional teams to deliver defined requirements and meet company strategic objectives. Support the full project life cycle including requirements gathering, creation of project plans and schedules, obtaining and managing resources, managing budget, and facilitating project execution, deployment and closure. Utilize corporate and in
Posted 2 months ago
Manager, Contracting & Network Development (1097693) Position Purpose Provide support for the management of physician, hospital and ancillary provider recruitment in accordance with corporate, health plan and state guidelines for assigned regions. Implement development activities for the recruitment and contracting of providers in provider networks in new and prospective markets Promote, maintain
Posted 2 months ago
Update and maintain provider computer records for assigned sites Add, change and terminate new or existing provider records in the medical information system Schedule monthly provider verifications regarding provider enrollment specifications and demographics Oversee Medicare and Medicaid provider directory process including achieving and maintaining compliance with the State and CMS with regards
Posted 3 months ago
Care Manager II (RN) (Field based) (1094682) Position Purpose 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. Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long ter
Posted 6 months ago
Vice President, Medical Management (1061833) Position Purpose Perform duties to direct and coordinate the medical management, quality improvement and credentialing functions for the assigned health plan based on, and in support of the company's strategic plan; establishing the strategic vision and attendant policies and procedures. Direct and coordinate activities of department and aid the chief o
Posted 14 months ago
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