Partner with UMR operations and Vendor partner, own the service experience of customers at the field level by working with the UMR Operations Team and other matrix partners as required to ensure issues are resolved promptly and accurately meeting the customers' expectations Develop and maintain solid relationship with internal partners in the UMR Service Team to manage cu

Build an Elite Team of Field Account Managers As a Director of Account Management, you will be responsible for leading a team of Field Account Managers to support execution of the client's daily activities Execution of customer satisfaction and retention Work directly with Strategic Account Executives, Project Manager, and Operation team to ensure your team is executing o

Coordinate Test Environment booking by different application teams Coordinate Test Environment upgrades and data refreshes with infrastructure implementation teams Required experience of PHI/PII data requirements Hold weekly review meeting with test environment stakeholder and share future bookings calendar. Required experience of managing technical implementations in non

Participates in the application technical design process with the Application Architects on development projects Ensures and contributes to testability of requirements and/or user stories Clarifies ambiguities in requirements, user stories, design and other artifacts produced as part of the product lifecycle Develops, implements, and maintains quality and test procedures,

Perform individual case review for appeals and grievances for various health plan and insurance products, which may include PPO, ASO, HMO, MAPD, and PDP. The appeals are in response to adverse determinations for medical services related to benefit design and coverage and the application of clinical criteria of medical policies Perform Department of Insurance/Department of

Serve as primary care manager for high medical risks / needs members with comorbid behavioral health needs Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic (SDoH) needs Develop and implement individualized, person centered care plans inclusiv

Assess, plan, and implement care strategies that are individualized by the member and directed toward the most appropriate, lease restrictive level of care Utilize both company and community based resources to establish a safe and effective case management plan for members Collaborate with patient, family, and healthcare providers Identify and initiate referrals for socia

Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medicati

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Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medicati

Leadership (Measured through performance metrics, Colleague Reviews) Overall local market health plan clinical operations for all products including achievement of annual clinical, quality/affordability and utilization management goals Local market SME for all clinical/medical management programs and contractual requirements Lead, coach/develop, trains (in conjunction wit

Positions in this function are responsible for providing expertise or general support to teams in reviewing, researching, investigating, negotiating, and resolving all types of appeals and grievances Communicates with appropriate parties regarding appeals and grievance issues, implications, and decisions Analyzes and identifies trends for all appeals and grievances May re

Implement and maintain data bases necessary to complete standard reportable event reports and analysis within agreed upon deadlines surrounding the HCBS LTSS population Complete ad hoc reports and analysis as requested by State partner or internal LTSS leadership Routinely analyze results of reportable event submissions, substantiations, and CAPs to identify trends such a

Develop, lead, and execute category management plans, competitive events, deal analysis, and complex negotiations for IT Software/Hardware and Services Support the end to end procurement process from sourcing through contracting, including pipeline management, in accordance with category strategy Review, develop, redline, and negotiate complex third party vendor contracts

Conduct financial and network pricing modeling, analysis and reporting Perform unit cost and contract valuation analysis in support of network contracting negotiations and unit cost management strategies Lead projects to completion by contributing to database creation, statistical modeling and financial reports Concisely summarize and communicate the results of complex an