The Recovery Specialist I is responsible for identifying and calculating overpayments and managing reimbursement processes from liable parties. They also issue refund request notices and adjust claims based on received payments.
The LPN/LVN is responsible for reviewing patient medical records, recording vital signs, and providing nursing interventions under physician direction. They will engage with patients telephonically to provide coaching and facilitate transfers to alternate levels of care.
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 documentation issues.
The Triage Nurse I determines appropriate care management programs for members by applying established clinical guidelines and criteria. They facilitate referrals, educate members on healthcare resources, and document clinical decisions accurately.
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 health management and medication adherence.
The Utilization Management Representative coordinates cases for precertification and prior authorization while determining contract and benefit eligibility. They manage incoming calls and claims work, referring clinical cases to nurses and maintaining positive customer relations.
The Clinical Pharmacist Sr. is responsible for developing and implementing pharmacy programs, including clinical consulting and education. They also assist in formulary development, perform drug utilization analyses, and present to the Pharmacy and Therapeutics committee.
The Pharmacy Technician II is responsible for interpreting and entering moderately complex prescriptions, processing prior authorizations, and troubleshooting adjudication issues. They also educate members on pharmacy rules and resolve grievances or appeals related to prescription benefits.
The Medical Management Clinician Senior reviews clinical information to assess medical necessity and ensure consistent administration of plan benefits for complex cases. They also serve as a resource for junior staff and collaborate with leadership on process improvement initiatives.
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 Credentialing Analyst supports licensing and credentialing efforts by performing complex file audits, managing appeals, and conducting research. They also interact with clinical leadership to resolve provider issues and ensure documentation accuracy according to company policies.
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 resources.
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 across the care continuum.
The Behavioral Health Care Manager manages psychiatric and substance abuse treatment benefits through telephonic or written review. They assess member needs using clinical judgment to ensure access to medically necessary care while promoting quality 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 Therapy Services Specialist performs telephonic and virtual assessments to identify participant needs and provides recommendations for supportive services. They also collaborate with clinical and support teams to document encounters and educate participants on home modifications and assistive equipment.
The Pharmacy Technician I is responsible for interpreting and entering prescription data, processing prior authorizations, and resolving adjudication issues. They also educate members on pharmacy rules and provide support for grievances, appeals, and formulary inquiries.
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 Behavioral Health Care Manager assesses clinical needs for 1915i waiver requests in collaboration with North Carolina Medicaid. They perform case planning, monitoring, and evaluation to ensure medically necessary behavioral healthcare and optimize member outcomes.
The Therapy Services Specialist Sr. supports new and current specialists by managing state-specific processes and conducting complex clinical assessments. They also assist in overseeing supportive service recommendations and provide mentorship during new hire orientation.
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 and ensure consistent application of medical policies across the organization.
The Psychologist Reviewer collaborates with providers and Medical Directors to determine the medical necessity and appropriateness of behavioral health services, including ABA and various therapy modalities. They also conduct pre-certification, concurrent reviews, and appeals while mentoring care management staff.
The OB/NICU 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 healthcare outcomes.
The Nurse Case Manager performs care management for members with complex and chronic needs by assessing, developing, and monitoring individualized care plans. They coordinate with medical groups, providers, and community resources to ensure appropriate service access and effective discharge planning.
The Advanced Practice Provider collaborates with physicians and interdisciplinary teams to develop and implement complex care plans for patients via telephone and tele-video modalities. They are responsible for gathering patient history, performing physical exams, identifying care gaps, and educating patients on medication and health management.
The Provider Escalations Analyst is responsible for resolving provider payment escalations and managing issues across all lines of business. They analyze claim impacts, interpret medical policies and contracts, and collaborate with internal and external partners to determine root causes.
The Provider Escalations Analyst Senior manages provider issues resolution across all lines of business, including investigating claim payment disputes and communicating medical and clinical policies. They also serve as a mentor, trainer, and liaison for internal and external business partners to facilitate process improvements.
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 educating families on health management.
The Nurse Case Manager performs care management for members with complex and chronic needs by assessing, developing, and implementing individualized care plans. They coordinate internal and external resources while monitoring the effectiveness of care to optimize health outcomes across the continuum.
The Pharmacy Customer Associate responds to customer inquiries via telephone and written correspondence regarding retail and mail order prescriptions. They coordinate with internal teams to resolve requests and assist customers in navigating pharmacy technology and resources.
The Provider Escalations Analyst is responsible for resolving provider payment escalations and managing issues across all lines of business. They analyze claim impact reports, interpret medical policies and provider contracts, and collaborate with internal and external partners to determine root causes.
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 resources for patients and their families.
The coordinator conducts outbound follow-up calls and emails to individuals in emotional distress to ensure they access recommended behavioral health services. They also coordinate referrals to local or state programs and dispatch mobile crisis teams when necessary.
The Behavioral Health Case Manager performs telephonic and home-based case management for members with behavioral health and substance abuse needs. They assess member needs, develop and monitor care plans, and coordinate with internal and external resources to ensure quality care.
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 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.
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.
