The Nurse Case Manager II is responsible for assessing, developing, and monitoring care plans for members with complex and chronic health needs. They coordinate internal and external resources while interfacing with medical directors to ensure appropriate service delivery.
The Medical Management Clinician Sr is responsible for reviewing clinical information to assess medical necessity and ensure consistent administration of plan benefits. They also serve as a resource for junior staff and collaborate with leadership on process improvement initiatives.
Identify and abstract HEDIS medical records throughout the year, conduct over-reads for compliance with HEDIS Technical Specifications, and review portal submissions against deadlines. Educate providers on HEDIS specifications and documentation, provide feedback on reviewed records, and develop expertise in annual HEDIS performance measure requirements.
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 records and coordinating care resources.
The Nurse Case Manager II assesses, develops, and monitors care plans for members with complex and chronic health needs to optimize their care across the continuum. They facilitate authorizations, coordinate resources, and collaborate with medical directors to ensure effective treatment and service delivery.
The Associate Genetic Counselor Reviewer conducts routine medical necessity clinical screenings for genetic testing pre-authorization requests. They collaborate with senior reviewers and medical directors to support complex cases and ensure compliance with clinical standards and department guidelines.
The Associate Medical Director is responsible for conducting timely clinical case reviews and making medical necessity determinations for requested services. They also facilitate physician-to-physician calls to gather necessary information and ensure consistent application of medical policies.
The Inpatient DRG Validator audits medical records to ensure accurate DRG assignment and generates high-quality recoverable claims. They also identify new claim types and provide process improvement recommendations to enhance audit efficiency.
The Outreach Care Specialist coordinates follow-up care plans and assesses member compliance with medical treatment through telephone or on-site visits. They also identify barriers to care, recommend process improvements, and coach members on reducing health risks.
The Advanced Practice Provider collaborates with physicians and interdisciplinary teams to develop and implement complex care plans for patients with chronic conditions. They provide primary and urgent healthcare via telephone and video modalities while maintaining accurate medical records and coordinating resources.
Coordinate precertification and prior authorization cases, determine contract and benefit eligibility, enter referral requests, and authorize eligible services. Handle customer inquiries across phone and written channels, refer cases requiring clinical review, and coordinate with internal teams to resolve requests promptly.
Assess members with complex or chronic care needs and develop, implement, coordinate, monitor, and adjust care plans to support appropriate access to healthcare services. Coordinate referrals, authorizations, providers, and internal and external resources, while collaborating with medical directors and physician advisors and assisting with discharge planning and service issues.
Assess members with complex or chronic care needs and develop, implement, coordinate, monitor, and evaluate care plans to support access to appropriate services. Coordinate referrals, authorizations, providers, and internal and external resources, while collaborating with medical directors and addressing care, claims, or service issues.
The Nurse Case Manager performs care management for members with complex and chronic needs by assessing, developing, and monitoring individualized care plans. They coordinate internal and external resources while facilitating authorizations and collaborating with medical directors to optimize health outcomes.
The Wound Care Utilization Management RN performs pre-certification and authorization activities for home health services to ensure clinical appropriateness. They collaborate with providers and home health agencies to develop care plans that promote healing and cost-effective resource utilization.
The Transitions of Care RN is responsible for delivering patient education, performing clinical assessments, and providing health coaching for members with chronic diseases. They coordinate care plans with providers and facilitate referrals to ensure effective health management.
The consultant provides 24/7 behavioral health and employee assistance services, including crisis intervention and short-term problem resolution. They also manage client requests, assess situations, and facilitate access to behavioral healthcare benefits.
The Prior Authorization Clinical Pharmacist evaluates and manages pharmaceutical utilization to ensure safe, effective, and cost-efficient medication use. They also prepare therapeutic class reviews and provide clinical guidance to network physicians and internal teams.
The Clinical Provider Auditor II identifies and investigates potential fraud, waste, and abuse by examining claims and medical records for billing compliance. They collaborate with the Special Investigation Unit to recommend interventions for loss control and risk avoidance.
The Nurse Case Manager performs care management for members with complex and chronic needs by assessing, developing, and monitoring individualized care plans. They coordinate internal and external resources, facilitate referrals, and collaborate with medical directors to optimize member health outcomes.
Interpret and communicate departmental and organizational policies, and receive, validate, and enter information into finance systems. Maintain and monitor internal controls and reconciliation tracking, conduct analysis, and resolve complex operational process issues.
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 ensure accurate claims payment and compliance with medical policies.
Collect past-due health insurance premiums and claims, research disputed or overdue debt, and prepare demand letters. Report on credit and collection activity for management review.
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 primary care via telephone and video modalities while maintaining accurate medical documentation 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 acute care via telehealth modalities while coordinating resources and educating patients and families on health management.
The Behavioral Health Case Manager performs telephonic and in-person assessments to identify member needs and develop effective care plans. They monitor the effectiveness of these plans while coordinating with internal and external resources to ensure quality, cost-effective care.
The Associate Medical Director supports medical management by conducting clinical case reviews and making medical necessity determinations for requested services. They also facilitate physician-to-physician calls and ensure consistent application of medical policies across the organization.
The DRG Clinical Validation Auditor is responsible for auditing inpatient medical records to ensure clinical documentation supports billed conditions and DRGs. They analyze claims by integrating coding principles and clinical guidelines to identify documentation errors and suggest process improvements.
The Crisis & Referral Specialist provides telephonic intervention and de-escalation for individuals in crisis while performing safety screenings and assessments. They also coordinate with agencies and support systems to ensure individuals access necessary services and resources.
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 optimal resource utilization and accurate documentation of all interactions.
The Crisis & Referral Specialist conducts telephonic safety screenings and assessments to determine the appropriate course of action for callers in crisis. They also coordinate with external agencies and maintain accurate documentation to ensure individuals receive necessary support and resources.
The Wellness & Recovery Specialist coordinates care and manages activities focused on the wellness and recovery of members. They identify engagement opportunities, implement psychiatric discharge planning, and act as a resource for staff and members.
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.
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.
