The Case Management Coordinator provides active care management, assesses service needs, and develops action plans to improve care coordination and member outcomes. They also perform medical necessity reviews, provide telephonic support for at-risk members, and ensure compliance with regulatory guidelines.
Perform medical claim reviews to determine medical necessity, appropriateness, and coverage based on clinical guidelines and protocol sets. Document medical rationale for payment or denial decisions and provide education to staff regarding medical terminology and coding procedures.
The Systems Programmer III is responsible for the administration, stability, and security of the IBM z/OS mainframe environment. This role involves managing the full lifecycle of the platform, including system programming, performance optimization, and disaster recovery support.
Perform medical claim reviews to determine medical necessity, appropriateness, and coverage based on established clinical guidelines. Document rationale for payment or denial decisions and provide guidance to team members while monitoring process timeliness.
The specialist will conduct market research to support product development and oversee the Medicaid Extra Benefits Program, including vendor management and budget oversight. They are responsible for leading marketing projects, ensuring compliance with SCDHHS requirements, and facilitating communication between stakeholders.
The Case Management Supervisor oversees daily functions including utilization review, case management, and quality management while supervising departmental staff. They are responsible for data collection, ensuring regulatory compliance, and developing work plans to improve quality performance.
The Senior Medical Reviewer acts as a team lead for specialty programs, providing guidance, training, and direction to staff to ensure appropriate healthcare service levels. They monitor workflows, participate in quality reviews, and resolve discrepancies while maintaining compliance with departmental standards.
The RN Behavioral Health Concierge Care Manager provides high-touch case management for members with complex or high-risk conditions to facilitate care coordination and gap closure. They are responsible for implementing program goals, managing treatment plans, and educating members on medications and prior authorizations.
Perform medical claim reviews to determine medical necessity, appropriateness, and coverage based on clinical guidelines. Document rationale for payment or denial decisions and educate staff on medical review and coding procedures.
The auditor is responsible for conducting financial, compliance, and operational audits to evaluate internal controls and identify business risks. They must draft detailed reports for executive management with recommendations to improve processes and ensure data integrity.
The Medical Director provides administrative oversight to medical staff, analyzes utilization data, and develops claim adjudication criteria. They also act as a liaison between the company and the medical community while researching new medical procedures and technologies.
The Medical Director provides administrative oversight to medical staff, analyzes utilization data, and develops claim adjudication criteria. They also act as a liaison between the company and the medical community while researching new medical procedures and policies.
Under general supervision, the Accounting Technician III performs a variety of routine to complex clerical and accounting functions. Responsibilities include inventory balancing, reconciliations, processing disbursements and deposits, and generating refund request letters.
