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Responsible for maintaining internal computer systems enrollment and membership records related to the qualifications for coverage under the contract or agreement. Respond to internal and external inquiries regarding eligibility/enrollment and maintain membership records. Oversee data integrity of member enrollment records and remittance files transmitted from the state Provide timely, efficient s
Posted 14 days ago
Perform duties related to the day to day operations of the Integrated Case Management functions to include working with members identified as high risk to identify needs and goals to achieve empowerment and improved quality of life for both behavioral and physical health issues. Assess members' current functional level and, in collaboration with the member, develop and monitor the Case Management
Posted 28 days ago
Vice President, Network Development & Contracting (1170417) Position Purpose Direct the provider network and contracting activities. Lead all aspects of provider network strategy including, access analysis, network operations and support decision makers with analysis related to reimbursement and unit cost management. Oversee the coordination and negotiation for the contracting department. Establis
Posted 28 days ago
Oversee the operation of the Contract Implementation Analyst and Claims Liaison teams Oversee the claims operation function, including contracting and configuration Monitor staff performance to identify any process or quality gaps and develop/implement business solutions to correct issues Provide management with necessary data to expedite resolution of claims issues and support in policy decisions
Posted 30 days ago
Conduct and manage the day to day operations of the Program Coordinators in the Case Management department. Develop and maintain efficient processes designed to timely facilitate case management referrals and member outreach. Ensure timely member enrollment into appropriate case management programs. Manage the day to day operations and functions of the Program Coordinators, including productivity
Posted 1 month ago
Perform duties to act as a liaison between providers, the health plan and Corporate. Perform training, orientation and coaching for performance improvement within the network and assist with claim resolution. Serve as primary contact for providers and act as a liaison between the providers and the health plan Conduct monthly face to face meetings with the provider account representatives documenti
Posted 1 month ago
Senior Transition Care Management Coordinator (1167911) Position Purpose Assist in day to day operations of clinical functions for the Post Hospital Outreach team. Act as primary liaison for clinical personnel to assist with member's post discharge medical needs. Serve as primary point of contact for clinical personnel and department liaison when the Supervisor is not available. Communicate with i
Posted 2 months ago
The Clinical Trainer for the Medical Management department isresponsible for developing and conducting a variety of training and trainingaudit programs and related tools. Conduct training needs analyses to determine specific training and auditingneeds for Medical Management department staff Identify, develop and conduct appropriate training programs, includingselecting and designing appropriate tr
Posted 2 months ago
Oversee day to day functions of the call center that provides preauthorization and referral services to physicians for plan members. Oversee preauthorization nurses and referral specialists in their day to day activities including management of talk times, service levels, abandonment rate, and other key quantitative/qualitative factors Develop, implement and maintain compliance, policies and proce
Posted 2 months 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. Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Utilize assessment ski
Posted 3 months ago
Perform duties related to the day to day operations of the Integrated Case Management functions to include working with members identified as high risk to identify needs and goals to achieve empowerment and improved quality of life for both behavioral and physical health issues. Assess members' current functional level and, in collaboration with the member, develop and monitor the Case Management
Posted 3 months ago
Oversee business operations, procurement opportunities, new product implementations and complex initiatives for business development utilizing cross functional business units and corporate teams to meet business unit and corporate strategic objectives. Partner with multiple stakeholders and leadership to establish strategic visions, operational objectives, and policies and procedures ensuring comp
Posted 3 months 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 4 months ago
Senior Transition Care Management Coordinator (1156171) Position Purpose Assist in day to day operations of clinical functions for the Post Hospital Outreach team. Act as primary liaison for clinical personnel to assist with member's post discharge medical needs. Serve as primary point of contact for clinical personnel and department liaison when the Supervisor is not available. Communicate with i
Posted 4 months ago
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