The CAP Clinical POC Reviewer evaluates Home and Community-Based Services waiver requests and Plans of Care against clinical criteria and Medicaid policies. They also prepare case determinations, perform second-level reviews, and serve as a clinical resource for internal and external stakeholders.
The Clinical Reviewer utilizes clinical expertise to review medical records against contract requirements and criteria. They are responsible for managing daily queues, ensuring accuracy, and acting as a liaison for provider customer service issues.
The role involves maintaining the Action Code Database by monitoring CMS regulatory updates and collaborating with internal teams and clients. Additionally, the associate performs utilization management by reviewing medical records to determine the medical necessity and appropriateness of requested services.
The Quality Improvement Coordinator supports contract growth by developing educational opportunities and maintaining a culture of continuous learning. They are responsible for establishing performance measurement systems, conducting quality studies, and ensuring compliance with contract deliverables.
The Clinical Reviewer is responsible for reviewing medical records against contract criteria and ensuring the accuracy and timeliness of review cases. They also act as a liaison for providers and collaborate with supervisors on quality monitoring activities.
The Clinical Reviewer utilizes clinical expertise to review medical records against established criteria and contract requirements. They also act as a liaison for providers, manage daily review queues, and collaborate on quality monitoring activities.
The Senior Program Director provides strategic and operational leadership for the CA Care Coordination Program, overseeing program design, daily operations, and regulatory compliance. They manage interdisciplinary teams to ensure equitable, person-centered support while monitoring metrics and collaborating with community partners.
The EAP Consultant performs clinical telephonic assessments, provides consultations, and manages referrals for employees and their families. They also offer management consultation services and ensure adherence to HIPAA privacy and security policies.
The Senior Technical Writer manages the creation and maintenance of high-quality documentation while providing leadership and guidance to junior team members. They collaborate with cross-functional teams to ensure all deliverables align with company standards and project-specific requirements.
The Senior Operations Support Analyst monitors operational performance, ensures SLA compliance, and manages system configurations and reporting accuracy. They also translate contractual requirements into effective workflows and provide tier 1 support to resolve operational and system issues.
The Clinical Business Analyst defines clinical requirements and collaborates with IT to deploy and maintain clinical platforms for case and utilization management. They act as a liaison between clients and technology teams, ensuring requirements are documented, tested, and aligned with business needs.
The Instructional Design and Training Associate is responsible for writing and editing learning content, creating job aids, and developing training materials for end-users. They also facilitate classroom training, maintain training environments, and collaborate with teams to support onboarding and educational initiatives.
The Senior Technical Writer manages the creation and maintenance of high-quality documentation while providing task leadership to junior team members. They collaborate with cross-functional teams to ensure all materials align with company standards and project-specific requirements.
Conduct administrative and process-based reviews of medical records related to Applied Behavior Analysis services to ensure compliance and medical appropriateness. Collaborate with supervisors on quality monitoring and serve as a liaison for providers regarding authorization requests.
The Medical Director provides clinical leadership and physician oversight for California transition-support services, ensuring member safety and adherence to clinical standards. They also consult with multidisciplinary staff, review complex cases, and support the development of clinical protocols and quality improvement initiatives.
The Care Coordinator identifies and coordinates service delivery for clients by matching them with qualified providers and arranging necessary support services. They also document interactions in electronic databases and educate families on available resources to ensure continuity of care.
The Provider Relations Professional serves as a liaison between the company and the provider network, managing outreach and engagement initiatives. They are responsible for maintaining network coverage, responding to provider inquiries, and ensuring accurate documentation of all interactions.
The AI Business Partner identifies and advances practical AI and automation opportunities to improve operational performance and user experience. They translate business needs into defined use cases and coordinate with cross-functional teams to support the discovery, planning, and delivery of AI initiatives.
The Banking Operations Analyst manages daily cash flow, treasury functions, and payment processing to ensure financial integrity. They also oversee bank reconciliations, maintain internal controls, and serve as the primary liaison with financial institutions and client fiscal offices.
The AI Business Partner identifies and advances practical AI and automation opportunities to improve operational performance and user experience within healthcare systems. They translate business needs into structured requirements and coordinate with cross-functional teams to support AI initiatives from discovery through delivery.
The Provider Enrollment Manager oversees daily provider network operations, recruitment, and enrollment programs while maintaining accurate internal and external databases. They serve as the primary point of contact for providers, ensuring compliance with contract deliverables and managing a multi-disciplinary team.
Strategically source, engage, and onboard physicians across various specialties for quality of care and utilization management review work. Manage the provider pipeline, negotiate market-specific rates, and ensure compliance with HIPAA and credentialing requirements.
The Senior EAP Consultant provides expert management and clinical consultation to support employee well-being and organizational health. Responsibilities include conducting clinical risk assessments, managing high-risk cases, and delivering training sessions in a virtual environment.
The Psychiatrist will conduct independent medical service appeal reviews and provide expert testimony for behavioral health cases. They are responsible for evaluating medical necessity, ensuring compliance with guidelines, and collaborating with clinical and administrative staff.
The Medical Claims Reviewer is responsible for auditing claims, medical records, and billing documentation to ensure compliance with Medicaid and program regulations. They also investigate billing irregularities, resolve provider disputes, and provide operational analysis to support program effectiveness.
Conduct needs-based eligibility determinations for Medicaid-funded personal care services and assess level of care for patients in home or community settings. Manage the assessment process, including interviews with caregivers, service plan reviews, and participation in mediation or appeal processes.
The Physician Medical Reviewer conducts independent medical service appeal reviews and provides expert testimony for state hearings. They ensure compliance with medical necessity guidelines and collaborate with clinical and administrative staff.
The EAP Consultant provides comprehensive tele-mental health services, including direct counseling, outreach, and referrals to employees and their families. They are responsible for maintaining clinical case records, managing high-risk cases, and collaborating with internal and external stakeholders to ensure high-quality service delivery.
The Developer, Specialist performs end-to-end analysis and implements complex business solutions while serving as a technical lead on development projects. They are responsible for creating technical specifications, evaluating new technologies, and guiding the development team through design and implementation phases.
The Case Manager will evaluate beneficiary needs, develop individualized care plans, and coordinate healthcare team members to ensure optimal outcomes. They are responsible for managing caseloads, maintaining accurate documentation, and ensuring compliance with regulatory requirements.
The peer reviewer will conduct medical record reviews to make standard of care determinations and provide quality improvement recommendations. They are responsible for discussing clinical disease processes and published guidelines while adhering to corporate policies and HIPAA regulations.
The peer reviewer will evaluate medical records to make standard of care determinations and provide quality improvement recommendations. They are responsible for discussing clinical disease processes and adhering to corporate policies including HIPAA.
The Provider Educator develops and delivers training programs to ensure compliance with Medicaid regulations and the WV IDDW Policy Manual. They also conduct provider reviews, provide technical assistance, and manage quality improvement initiatives.
The peer reviewer will evaluate medical records to make standard of care determinations and provide quality improvement recommendations. They are responsible for discussing clinical disease processes and adhering to all corporate policies, including HIPAA regulations.
The Operational Readiness Professional ensures that systems, processes, and workflows are fully prepared for launch and aligned with CMS contract requirements. They lead readiness assessments, manage milestone plans, and collaborate with cross-functional teams to mitigate risks and ensure operational success.
The developer will be responsible for building and maintaining PHP-based applications while managing databases and cloud infrastructure. They will also implement security measures, automate tasks using BASH scripts, and collaborate with the team on project management.
