The RN Behavioral Health Concierge Care Manager provides high-touch case management for members with complex or high-risk conditions to ensure effective care coordination. They are responsible for implementing program goals, managing treatment plans, and facilitating communication between providers, facilities, and patients.
The consultant educates medical providers on Medicare coverage, documentation, and utilization statistics through written materials and formal workshops. They also analyze provider billing practices to identify over-utilization and coordinate with the medical review department to address compliance issues.
Develops and produces educational materials and training programs for network providers, physicians, and beneficiaries. Acts as a liaison between the organization and various stakeholders to ensure training needs are met and issues are resolved.
The Appeals Analyst researches complex appeal and retrospective review requests to determine medical necessity based on clinical documentation and contractual guidelines. They are responsible for documenting decisions accurately while ensuring compliance with applicable regulations and confidentiality standards.
Perform medical claim reviews to determine medical necessity and appropriateness based on established clinical guidelines and protocols. Document medical rationale for payment or denial decisions and provide education to staff regarding medical reviews and coding procedures.
The auditor will analyze and authorize reimbursement for medical stop loss claims while identifying cost mitigation opportunities. They are also responsible for conducting claims investigations, managing vendor referrals, and providing comprehensive claims service to inquiries.
The Lead Auditor coordinates and executes complex audit reviews, including cost reporting and operational control assessments. They also provide leadership, training, and guidance to department staff while ensuring compliance with professional auditing standards.
Conduct operational, compliance, and financial audits; assess risks and internal controls; and analyze records and data to identify deficiencies, fraud, or non-compliance. Document findings, test corrective actions, and prepare reports with recommendations to improve processes and reduce risk.
The Intensive Care Management Coordinator will perform assessment, planning, and coordination of care for members with behavioral health conditions. This role involves conducting in-person patient visits and collaborating with families and healthcare professionals to ensure effective health management.
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 research new medical procedures and act as a liaison between the company and the medical community.
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 education to staff regarding medical terminology and coding procedures.
The auditor conducts financial, compliance, and operational audits to evaluate internal controls and identify business risks. They also draft reports for executive management with recommendations to improve processes and ensure data integrity.
The Medical Director analyzes medical review utilization data and develops claim adjudication criteria for medical and regulatory matters. They also act as a lead resource for providers and internal staff while conducting research on new medical procedures and technology.
The Molecular Diagnostics Medicare Medical Director oversees medical staff, analyzes utilization data, and researches emerging molecular technologies to support Medicare coverage decisions. They also develop medical policies and serve as a liaison between the company and the medical community.
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.
