The Inpatient DRG Validator audits medical records to ensure accurate DRG assignment and generates high-quality recoverable claims. They analyze claims by integrating coding principles and clinical guidelines to substantiate audit findings and identify potential recovery opportunities.
The Nurse Case Manager II 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 authorizations, and collaborate with medical directors to optimize healthcare outcomes.
The DRG Clinical Validation Auditor is responsible for auditing inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed. They analyze claims by integrating coding principles and clinical guidelines to substantiate audit determinations and identify documentation errors.
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 authorizations, and collaborate with medical directors to optimize member health outcomes.
The Medical Management Nurse evaluates the medical necessity of complex cases by applying clinical guidelines and nursing judgment. They collaborate with healthcare providers and the Medical Director to optimize member outcomes and ensure appropriate care levels.
The Medical Management Nurse evaluates the medical necessity of complex cases by applying clinical guidelines and nursing judgment. They collaborate with healthcare providers and internal leadership to optimize member outcomes and improve organizational processes.
The Nurse Case Manager II assesses, develops, and monitors care plans for members with complex and chronic health needs. They coordinate internal and external resources while facilitating authorizations and collaborating with medical directors to optimize health outcomes.
Assess members receiving transplant services, develop and coordinate individualized care plans, and monitor outcomes across the care continuum. Review medical necessity and treatment settings, coordinate with providers and medical directors, support care transitions, and help ensure high-quality, cost-effective care that complies with applicable policies and standards.
Investigate and process complex behavioral health grievances and appeals, reviewing medical records and summarizing clinical information to support medical necessity decisions. Prepare recommendations for medical director approval, ensure timely regulatory resolution, document case activity, communicate decisions, and contribute to medical policy and managed care projects.
The Nurse Case Manager II 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 authorizations, and collaborate with medical directors to optimize health outcomes.
The Medical Director is responsible for conducting clinical case reviews to ensure consistent medical necessity determinations for services. They also facilitate physician-to-physician calls and manage grievance and appeals processes within their specialty.
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 stakeholders.
Review and prioritize patient census, contact patients to explain services, and enroll them in appropriate programs. Respond to inquiries, schedule initial and annual appointments, and document interactions while managing calls, texts, faxes, and electronic queues.
The Telephonic Nurse Case Manager II assesses, develops, and monitors care plans for members with complex and chronic needs to optimize health outcomes. They coordinate internal and external resources, facilitate authorizations, and collaborate with medical directors to ensure appropriate service delivery.
Respond to helpline callers seeking support or experiencing a crisis, conduct safety screenings and risk assessments, and collaborate with callers to determine an appropriate course of action. Document interactions accurately, coordinate referrals and resources, provide follow-up as directed, and comply with applicable regulations.
Research and evaluate health claims involving potential third-party liability, workers' compensation, and other subrogation or reimbursement recoveries. Analyze claim-related documents and data, determine relatedness and reimbursement amounts, respond to inquiries, maintain case files, coordinate payment accounting, and negotiate settlements within delegated authority.
The Telephonic Nurse Case Manager II assesses, develops, and monitors care plans for members with complex and chronic health needs. They coordinate internal and external resources while interfacing with medical directors to optimize health care outcomes.
The Nurse Case Manager is responsible for managing care for members with complex needs through assessment, planning, and coordination of services. They monitor the effectiveness of care plans and collaborate with medical directors and providers to improve clinical outcomes.
The Crisis & Referral Specialist conducts telephonic safety screenings and assessments to determine the acuity of risk for callers. They develop collaborative action plans and coordinate with external agencies to ensure individuals receive necessary behavioral health support.
The Crisis & Referral Specialist provides telephonic intervention and de-escalation for helpline callers using established protocols. They perform safety screenings, assess risk, and coordinate with agencies to ensure optimal use of resources and services.
The Medical Director manages medical services to ensure members receive appropriate, cost-effective care while providing clinical and strategic guidance. They conduct peer-to-peer clinical reviews and implement programs to improve healthcare quality, outcomes, and cost-efficiency.
The Medical Management Nurse reviews complex cases to determine medical necessity using clinical judgment and critical thinking. They collaborate with healthcare providers and the Medical Director to optimize member outcomes and ensure appropriate care levels.
The Medical Management Nurse evaluates complex clinical cases to determine medical necessity and collaborates with healthcare providers to optimize member outcomes. They also serve as a clinical resource for staff, participate in process improvement initiatives, and assist with training and orientation materials.
The Medical Director oversees medical services to ensure cost-effective, high-quality care and provides clinical strategic advice to enhance operations. They lead clinical programs, conduct peer-to-peer reviews, and develop medical policies to improve healthcare outcomes.
The Nurse Case Manager performs care management for members with complex needs by assessing, developing, and implementing individualized care plans. They coordinate internal and external resources while monitoring the effectiveness of care across the continuum to optimize member health outcomes.
Reviews behavioral health outpatient services, primarily Applied Behavior Analysis, to determine appropriate levels of care based on medical necessity criteria. Collaborates with providers, BCBAs, medical directors, and internal staff on utilization reviews, appeals, staff mentoring, and initiatives related to psychological and neuropsychological testing.
Research and synthesize clinical pharmaceutical data, prepare therapeutic class reviews and drug monographs, and support formulary management and drug utilization review programs. Review pharmaceutical coverage decisions based on medical necessity criteria where permitted, and provide clinical guidance to pharmacists, physicians, and internal stakeholders.
Provides primary and urgent care remotely to adult patients with chronic and complex conditions, developing and implementing individualized care plans based on clinical needs and patient goals. Coordinates care with patients, families, physicians, and interdisciplinary teams; addresses care gaps, educates patients, documents services, and prescribes medication as permitted by state law.
Assess members with complex or chronic care needs and develop, implement, coordinate, monitor, and evaluate care plans to optimize health outcomes across the care continuum. Coordinate services and resources, facilitate authorizations and referrals, collaborate with medical directors and providers, and address care, claims, or service issues by telephone.
Assess members receiving transplant services and develop, coordinate, monitor, and adjust care plans to address their healthcare needs. Review medical necessity and treatment settings, coordinate with providers and clinical reviewers, facilitate care transitions, and support access to high-quality, cost-effective care.
The Outreach Care Specialist coordinates follow-up care plans, assesses member compliance with medical treatment, and identifies barriers to care. They also coach members on health risks and recommend process improvements to meet quality goals.
The Clinical Review Nurse I is responsible for assessing the necessity and reasonableness of items in medical claims. They perform complex medical determinations to ensure claims align with member benefits and medical policies.
The Nurse Care Manager is responsible for assessing the medical necessity of inpatient and outpatient services to ensure high-quality, cost-effective care. They collaborate with healthcare providers and consumers to develop and monitor personalized care plans for members with complex and chronic needs.
Assess members with complex or chronic care needs and develop, implement, coordinate, monitor, and evaluate care plans to improve health outcomes across the care continuum. Coordinate services and resources, facilitate authorizations and referrals, collaborate with medical directors and providers, and assist with discharge planning and service-related issues.
Provides telephonic health coaching and education to disease management program members, supporting behavior change, self-management, and improved health outcomes. Assesses members’ needs and barriers, develops individualized action plans, encourages preventive care, and may coordinate with multidisciplinary clinical teams.
Investigate and review member and provider medical necessity appeals by evaluating medical records, applying clinical criteria and policies, and preparing approval determinations or recommendations for medical director review. Resolve and document appeals and grievances within regulatory timeframes, communicate decisions to relevant parties, and support teams as a subject matter expert.
Assess members with complex or chronic care needs and develop, implement, coordinate, monitor, and adjust care plans to support appropriate access to services. Coordinate referrals, authorizations, and internal and external resources; collaborate with medical directors and providers; and assist with discharge planning, reimbursement negotiations, and care management policies.
The Social Work Case Manager is responsible for providing psychosocial interventions and coordinating resources to help patients manage chronic illnesses. They evaluate member strengths and needs to develop and implement effective health self-management strategies.
The Peer Recovery Specialist coordinates care and manages wellness activities for members while facilitating supportive recovery networks. They collaborate with case management teams to provide discharge planning education and resolve barriers to service transitions.
The Pharmacy Technician II is responsible for interpreting and entering moderately complex prescriptions, processing prior authorizations, and troubleshooting adjudication issues. They also provide resolution to grievances and appeals while educating members on medication adherence and preventive screenings.
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 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.
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.
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 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.
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.
