The Clinical Pharmacist manages pharmaceutical utilization and supports clinical programs such as formulary management and drug utilization reviews. They are responsible for reviewing coverage requests based on medical necessity and providing clinical support to internal stakeholders and physicians.
The Outreach Care Specialist coordinates member treatment plans, schedules appointments, and assesses compliance to improve health outcomes. They also identify barriers to care, recommend process improvements, and facilitate referrals to community resources.
The Pharmacy Technician I is responsible for interpreting and entering basic prescriptions, processing prior authorizations, and troubleshooting adjudication issues. They also educate members on pharmacy rules and provide resolution for grievances and appeals.
The Coding Analyst Sr. is responsible for auditing and coding medical records to ensure accurate reimbursement and compliance. They also provide training and education to staff while serving as a resource for complex coding and billing inquiries.
The Crisis Clinician Lead performs direct call handling, including screening and telephonic intervention for callers in crisis. Additionally, they provide clinical guidance to staff, monitor call volumes, and assist management with unit operations and complex case management.
The PBM Billing Specialist Senior is responsible for maintaining the billing system database and reconciling data discrepancies. They also coordinate account eligibility with membership departments and provide billing information to internal and external stakeholders.
The Account Service Specialist maintains relationships with account teams through regular communication and assists in the coordination of new client implementation and onboarding. They are responsible for providing ongoing customer service support to ensure client needs are met effectively.
The Nurse Case Manager I assesses, develops, and monitors care plans for members with complex and chronic health needs to optimize care across the continuum. They facilitate authorizations, coordinate resources, and collaborate with medical directors to ensure appropriate service access.
The Nurse Practitioner collaborates with physicians and interdisciplinary teams to develop and implement complex care plans for patients in home and community-based settings. They provide urgent care via telephone and video modalities while educating patients and families on medication, illness progression, and health maintenance.
The Maternal Child Nurse Case Manager performs care management for members with complex needs by assessing, developing, and monitoring individualized care plans. They coordinate internal and external resources, facilitate referrals, and collaborate with medical directors to optimize health outcomes.
The Provider Network Manager Sr is responsible for developing provider networks through complex contract negotiations and relationship management. They also serve as a key resource for mentoring staff and collaborating on enterprise-level network management projects.
The Clinical Quality Program Manager oversees quality improvement initiatives and serves as a liaison for state-level business lines. They are responsible for leading root cause analyses, developing performance improvement plans, and ensuring compliance with regulatory and accreditation standards.
The Nurse Practitioner collaborates with physicians and interdisciplinary teams to develop and implement complex clinical care plans for patients in home and community-based settings. They provide primary and urgent care via telephone and video modalities while maintaining accurate medical documentation and coordinating care resources.
The specialist is responsible for care coordination and management activities focused on the wellness and recovery of members. They will identify engagement opportunities, implement discharge planning education, and collaborate with stabilization teams to support service transitions.
The Nurse Practitioner will provide urgent health care via telephone and video modalities to patients in home and community-based settings. They are responsible for developing complex clinical plans of care and coordinating with inter-disciplinary teams to meet patient health goals.
The Nurse Practitioner collaborates with physicians and interdisciplinary teams to develop and implement complex clinical care plans for patients in home and community-based settings. They provide urgent and acute care via telephone and video modalities while educating patients and families on health management and medication adherence.
The Nurse Case Manager II assesses, develops, and implements care plans for members with complex and chronic needs to optimize health outcomes. They coordinate internal and external resources, facilitate referrals, and monitor the effectiveness of care management strategies.
The Nurse Case Manager performs care management for members with complex and chronic needs by assessing, developing, and monitoring individualized care plans. They also coordinate internal and external resources while interfacing with medical directors to ensure appropriate service delivery.
The Pharmacist Consultant evaluates member medication needs and therapy appropriateness while assessing compliance through direct contact with patients and physicians. They also serve as a clinical resource for disease management programs and provide counseling on alternative medication therapies.
The Nurse Practitioner collaborates with physicians and interdisciplinary teams to develop and implement complex clinical care plans for patients in home and community-based settings. They provide primary care via telephone and video modalities while educating patients and families on medication, illness progression, and health maintenance.
The Nurse Practitioner collaborates with physicians and interdisciplinary teams to develop and implement complex clinical care plans for patients in home and community-based settings. They provide urgent care via telehealth modalities and educate patients and families on medication, illness progression, and health maintenance.
The Behavioral Health Care Manager II manages ABA pre-certification health benefits through clinical review and assessment. They ensure members have access to medically necessary behavioral healthcare while optimizing the use of health benefits and community resources.
The Therapy Services Specialist performs telephonic and virtual assessments to identify participant needs and provides recommendations for supportive services. They also collaborate with clinical teams and managed care organizations to document encounters and educate participants on adaptive equipment.
The Nurse Practitioner collaborates with physicians and interdisciplinary teams to develop and implement complex clinical plans of care for patients in home and community-based settings. They provide primary and urgent healthcare via telephone and tele-video modalities while maintaining accurate medical records and coordinating care resources.
The Nurse Practitioner collaborates with physicians and interdisciplinary teams to develop and implement complex clinical care plans for patients in home and community-based settings. They provide primary and urgent care via telephone and video modalities while educating patients and families on health management and medication adherence.
The Crisis & Referral Specialist provides telephonic intervention and de-escalation for helpline callers while performing safety screenings and assessments. They also coordinate with agencies and organizations to ensure optimal use of resources and maintain accurate documentation of all interactions.
The Transitions of Care RN is responsible for delivering patient education, performing disease management interventions, and providing health coaching for members with chronic diseases. They will conduct clinical assessments, coordinate care plans, and facilitate referrals to appropriate health professionals and community agencies.
The DRG Clinical Validation Lead assesses the medical necessity of inpatient and outpatient services to ensure high-quality, cost-effective care. They also lead cross-functional teams and collaborate with medical directors to interpret appropriateness of care and accurate claims payment.
The auditor is responsible for reviewing inpatient medical records to ensure clinical documentation supports billed DRGs and reimbursement. They analyze claims by integrating coding principles and clinical guidelines to identify documentation errors and suggest process improvements.
The Crisis & Referral Specialist performs safety screenings and telephonic interventions for individuals in crisis to determine appropriate courses of action. They also coordinate with external agencies and organizations to ensure callers access necessary resources and support services.
The Nurse Practitioner collaborates with physicians and interdisciplinary teams to develop and implement complex clinical care plans for patients in home and community-based settings. They provide urgent care via telehealth modalities and educate patients and families on medication, health maintenance, and crisis prevention.
The reviewer conducts clinical case evaluations to determine the medical necessity of therapy services and ensures consistent, compliant decision-making. They also lead peer-to-peer calls with providers and document findings in accordance with regulatory standards.
The Therapy Services Specialist performs telephonic and virtual assessments to identify participant needs and provides recommendations for supportive services. They also educate participants on home modifications and assistive technology while collaborating with the clinical team to document member encounters.
Collaborate with providers and Medical Directors to determine the appropriateness of care levels based on Medical Necessity Criteria, primarily for ABA services. Conduct pre-certification, concurrent reviews, and appeals while mentoring Behavioral Health Care Management staff.
Responsible for interpreting and entering moderately complex prescriptions and processing prior authorizations for Medicare, Medicaid, and Commercial members. The role involves educating members on medication adherence and coordinating with providers to close care gaps.
The Behavioral Health Care Manager I conducts utilization management reviews for mental health and substance use disorder benefits. This includes assessing member needs and coordinating care to promote quality outcomes and effective use of health benefits.
The Behavioral Health Care Manager II is responsible for managing psychiatric and substance abuse treatment through telephonic or written review. This role involves assessing member needs, coordinating care, and promoting effective use of health benefits.
