The Care Coordinator manages member caseloads by providing health navigation, performing risk assessments, and facilitating communication within an interdisciplinary care team. They are responsible for documenting member interactions in the PHI system and conducting outreach to ensure services are effectively implemented.
Care coordinators manage member caseloads by providing health navigation, performing risk assessments, and documenting interactions in the PHI system. They also collaborate with interdisciplinary teams to ensure timely communication and confirm that necessary services are in place for members.
The Clinical UM Pharmacist reviews prior authorization requests for medications under the medical benefit and develops clinical criteria and medical policies. They also collaborate with prescribing physicians and Medical Directors to ensure clinical appropriateness and compliance with CMS and NYSDOH regulations.
The Grievance Specialist manages the full lifecycle of member grievances, including investigation, research, and resolution. They collaborate cross-functionally to ensure compliance with regulatory standards and maintain accurate case documentation.
The Appeals Specialist is responsible for processing non-clinical member and provider appeals while ensuring compliance with federal and state regulations. They independently research issues, interpret health plan policies, and manage their own caseload to resolve denials and complaints.
The A&G Clinical Specialist manages clinical case development and resolution for member complaints, grievances, and appeals while ensuring compliance with regulatory standards. They are responsible for researching issues, interpreting health plan policies, and preparing cases for Medical Director review or external appeal processes.
The manager oversees clinical appeal inventory and staff assignments to ensure regulatory compliance and high-quality output during weekend shifts. They also manage vendor relationships, coordinate case escalations, and implement process improvements to meet production targets.
The Software Production Support Lead ensures the stability and performance of products by managing ticket escalations, performing root cause analysis, and coordinating with cross-functional teams. They are responsible for tracking SLAs, generating performance metrics, and providing technical guidance to resolve issues efficiently.
The Support Coordinator assists care managers with non-clinical tasks such as managing authorizations, creating cases, and conducting telephonic outreach to members and providers. They are responsible for maintaining accurate documentation, ensuring HIPAA compliance, and providing high-quality customer service to resolve member and provider inquiries.
The Manager of Clinical Appeals and Grievances leads a team to standardize and optimize appeal processes while ensuring compliance and high-quality case resolution. This role collaborates with organizational leaders to identify priority focus areas and manages internal and external production teams to meet performance targets.
The Outreach Retention Specialist is responsible for managing member outreach and retention efforts to support organizational goals. They will engage with members to ensure service continuity and address inquiries effectively.
The Clinical Specialist manages member complaints, grievances, and appeals by conducting clinical case development and resolution. They ensure compliance with federal and state regulations while managing caseloads and preparing cases for medical director review.
The analyst leads end-to-end forecasting and capacity planning for multichannel contact center operations, ensuring strategic alignment and performance oversight. They translate demand forecasts into actionable staffing strategies while driving continuous improvement in models and methodologies.
The Vendor Partner Specialist manages relationships with external vendors to ensure service level agreement adherence and quality auditing. They act as a liaison between department leaders and vendors to coordinate workflow, training, and process improvements.
The Medical Peer Reviewer consults on medical necessity within utilization management, ensuring adherence to internal and external regulations by assessing authorization requests and claims payments based on medical records. This role involves rendering determinations within regulatory timeframes, maintaining productivity standards, and collaborating across various medical and management departments.
