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.
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.
Perform medical claim reviews to determine medical necessity, appropriateness, and coverage based on established clinical guidelines. Document rationales for payment or denial and provide education to staff regarding medical review processes and coding.
The RN Appeals Analyst researches complex appeal and retrospective review requests to determine medical necessity based on clinical documentation and benefit guidelines. They document decisions accurately while ensuring compliance with regulatory standards and confidentiality requirements.
Evaluate and manage catastrophic illness episodes for underwriting and claims, including estimating medical costs, consulting with underwriters, and reviewing potential and excess claims to establish reserves. Oversee managed care between the third-party administrator and the company, researching cost-containment opportunities and coordinating interventions to support appropriate, cost-effective care.
Conduct internal and external financial, compliance, and operational audits to evaluate internal controls and business risks. Draft audit reports for executive management with recommendations to improve processes and ensure data integrity.
The consultant provides education to medical providers regarding Medicare coverage, utilization statistics, and documentation requirements. They also conduct formal educational visits and workshops to address over-utilization and billing practices.
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 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.
