The representative is responsible for ensuring provider data integrity and managing provider directory categorization. They also handle provider inquiries, assist with network development, and ensure compliance with CMS and NCQA standards.
The specialist performs quality initiatives to improve member care by managing medication adherence and conducting telephonic outreach. They also educate members and providers on quality metrics while maintaining accurate records in the tracking system.
This role manages member experience improvement initiatives, including survey ratings and NCQA accreditation processes. The manager also develops training materials and collaborates with internal and external stakeholders to meet quality performance standards.
The Clinical Quality Specialist manages care gaps through data entry, referral tracking, and provider outreach. They also educate providers on quality metric guidelines and conduct medical record audits to ensure compliance with CMS standards.
The Case Manager performs telephonic case management for high-risk members to improve long-term wellness through assessment, care planning, and coordination. They also act as a patient advocate, ensuring quality care and educating members on self-management techniques.
The Chart Retrieval Specialist manages and abstracts member health records across various electronic systems to support risk adjustment audits. They are responsible for coordinating data collection through fax campaigns and provider office visits while meeting daily and weekly project goals.
This role provides administrative support for utilization review, health education, and care management. Responsibilities include managing member and provider communications, processing authorization requests, and maintaining medical records in compliance with HIPAA.
Perform telephonic case management for high-risk members to improve long-term wellness through care coordination and monitoring. Educate members and caregivers on self-management techniques and coordinate services with providers and community resources.
