The RN will provide oversight, assessment, and guidance to participants in the IRIS Self-Directed Personal Care program. Responsibilities include developing person-centered care plans, conducting home visits, and providing training to participants and care providers.
Leads the enterprise strategy and operating framework for Artificial Intelligence governance, vendor oversight, and regulatory compliance across the AI lifecycle. Establishes policies, controls, and monitoring practices to ensure the responsible, secure, and scalable adoption of AI solutions within the organization.
Manage a caseload of Medicare members through telephonic assessments, care coordination, transition-of-care support, and ongoing monitoring of individualized care plans. Collaborate with members, caregivers, clinicians, and interdisciplinary teams to address barriers, connect members with behavioral health and community resources, and support quality, cost-effective outcomes.
The role involves leading complex investigations into insider threats by analyzing technical and behavioral data to identify and mitigate risks. The investigator will partner with cross-functional teams to develop detection strategies, report findings to leadership, and enhance the overall Insider Threat Program.
The specialist is responsible for developing and implementing clinical quality member intervention initiatives across various lines of business. They monitor program activities, interpret regulatory specifications, and facilitate strategic relationships with community-based organizations to improve health outcomes.
The Care Manager provides support for long-term services and supports (LTSS) by coordinating integrated care for members with high-need potential. Responsibilities include conducting comprehensive assessments, developing care plans, and facilitating interdisciplinary care team meetings to ensure quality and cost-effective outcomes.
The Care Manager coordinates integrated member care by conducting behavioral health assessments and developing collaborative care plans. They monitor member progress, facilitate interdisciplinary team meetings, and provide ongoing outreach to ensure quality and cost-effective outcomes.
Leads data intelligence strategy for procurement efforts by collecting and analyzing performance metrics to strengthen RFP responses. Collaborates with cross-functional stakeholders to curate operational, clinical, and claims data while conducting competitive market analysis.
Facilitate the research and resolution of member and provider appeals, grievances, and complaints in accordance with CMS standards. Ensure all correspondence and documentation are accurate, timely, and compliant with regulatory requirements.
The Senior Specialist provides clinical support for quality management programs, including audits, data analysis, and compliance activities. They are responsible for monitoring quality of care, performing medical record reviews, and implementing strategies to improve patient safety and clinical outcomes.
The Lead Specialist oversees the submission, intervention, and resolution of member and provider appeals and grievances in accordance with CMS standards. They also provide team leadership, train new employees, and resolve complex escalated claims issues.
Plan and support the deployment of clinical systems, programs, technologies, and workflows, coordinating with clinical, technical, and administrative teams to ensure regulatory compliance and smooth adoption. Monitor implementation outcomes, troubleshoot issues, analyze program data, and recommend workflow and system improvements.
The Director leads the development and delivery of population health strategies, including clinical program design and initiatives focused on member equity and social determinants of health. They oversee state health plan strategic design, manage operational budgets, and collaborate with clinical and operational stakeholders to drive program performance.
The Senior Analyst develops analytics and reporting to support out-of-network provider liability models and negotiation strategies. They integrate complex datasets to provide actionable insights for IDR performance, financial impact, and dispute outcomes.
Facilitate transitional care processes for members moving from hospital settings to home or nursing facilities to reduce readmissions. Conduct face-to-face visits, coordinate with interdisciplinary teams, and educate members on medication and health management.
Develop and maintain business requirements for coverage, reimbursement, and system changes, ensuring alignment with regulatory and health plan requirements. Coordinate with stakeholders and subject matter experts to interpret requirements, support implementation, improve processes, and communicate impacts and progress.
Provides level II support to health plan members and providers across communication channels, resolving inquiries about benefits, claims, eligibility, premiums, authorizations, and related services. Documents interactions, assesses urgency and escalation needs, collaborates with stakeholders, and supports service quality, process improvement, and member and provider retention.
Build trusting relationships with IRIS participants, help them identify and achieve long-term care goals, and connect them with community resources while ensuring plans comply with program requirements and budgets. Provide program orientation, document participant plans and progress in WISITs, support budget and provider-related processes, and collaborate with agency staff.
Conduct personal care assessments using the Wisconsin Personal Care Screening Tool, develop and oversee person-centered care plans, and obtain and review physician orders. Provide training and education to participants and care providers, coordinate with other care professionals, and complete required documentation, follow-up, and prior authorization submissions.
Develop and execute provider engagement plans that improve quality performance and risk adjustment accuracy across Medicaid, Medicare, and Marketplace programs. Coach providers, address practice barriers, coordinate data and training activities, and track engagement outcomes in collaboration with health plan teams.
The manager will collaborate with quality leaders to execute performance improvement initiatives and manage quality data collection strategies. They are responsible for overseeing data ingestion, ensuring regulatory audit compliance, and identifying opportunities to close quality care gaps.
The investigator is responsible for preventing, detecting, and investigating health care fraud, waste, and abuse through data analysis and medical record reviews. They must also prepare detailed reports and referrals for regulatory agencies and law enforcement while ensuring compliance with contractual requirements.
The Senior Analyst supports enterprise projects by translating regulatory and business needs into effective operational solutions. They collaborate with stakeholders to improve processes, manage change, and ensure system alignment with regulatory requirements.
The investigator will re-evaluate medical claims and records to identify and resolve instances of provider coding fraud, waste, and abuse. They will manage caseloads, ensure regulatory compliance, and facilitate referrals to law enforcement or payment recovery.
Review provider claims denials by examining medical records, denial reasons, submitted claims, and claim history to determine whether documentation supports the services billed. Audit billing accuracy, uphold or overturn denials, communicate determinations to providers, document coding issues, and support compliance and process improvements.
The Care Manager provides telephonic support and care coordination for Medicaid members with complex health or behavioral diagnoses. They are responsible for developing care plans, conducting assessments, and facilitating interdisciplinary team meetings to ensure quality member outcomes.
The Care Manager provides comprehensive behavioral health assessments and develops integrated care plans for Medicaid members with complex needs. They facilitate interdisciplinary team meetings and conduct ongoing monitoring to ensure member progress and continuity of care.
The manager oversees and implements health plan quality improvement activities to ensure compliance with state, federal, and NCQA regulatory requirements. They lead cross-functional teams, manage project plans, and prepare detailed reports on quality performance and audit results.
The Transition of Care Coach facilitates the discharge process for members to ensure safe transitions and reduce hospital readmissions. They conduct face-to-face visits, coordinate care with interdisciplinary teams, and educate members on medication management and follow-up care.
The Care Manager provides telephonic case management and coordinates integrated care for Medicare members across the continuum. They are responsible for conducting comprehensive assessments, developing care plans, and facilitating interdisciplinary team meetings to ensure quality outcomes.
Provides enterprise executive leadership for clinical operations, ensuring regulatory compliance, operational excellence, and high-quality member outcomes. Oversees centralized clinical audits, workforce strategy, vendor accountability, and clinical data insights to drive continuous improvement.
Provide level II support to Molina members and providers through phone, chat, and email channels. Resolve inquiries regarding benefits, claims, and eligibility while maintaining accurate documentation and meeting performance goals.
Leads and directs the enterprise-wide Medicare Stars quality improvement programs to enhance performance and ensure compliance with federal and NCQA standards. Facilitates cross-functional collaboration to develop intervention strategies and manages team performance to achieve departmental goals.
The IRIS Consultant builds relationships with participants to help them navigate the Medicaid long-term care program and achieve their personal goals. They are responsible for developing customized care plans, managing budgets, and documenting all activities within the program's data system.
The Community Connector serves as a local advocate to help vulnerable members navigate health care needs and access social services. Responsibilities include conducting field-based outreach, scheduling appointments, and assisting members in maintaining Medicaid eligibility.
The manager oversees the end-to-end development and delivery of Medicare member-facing documents, including Welcome Kits and Provider Directories. They ensure regulatory compliance with CMS and state requirements while coordinating across multiple internal teams and health plan markets.
The Senior Analyst will extract, analyze, and synthesize medical data to identify financial risks and opportunities while supporting executive decision-making. They will also lead projects to monitor health plan performance and provide actionable recommendations to improve medical cost trends.
The Account Manager provides subject matter expertise for Medicare sales activities and manages relationships with strategic distribution partners. They are responsible for driving membership growth, identifying new revenue opportunities, and ensuring compliance with CMS regulatory requirements.
The coordinator manages member intake and care coordination portal operations while facilitating referrals and monitoring program metrics. They also build partnerships with community organizations and ensure member inquiries are addressed timely.
The representative handles inbound and outbound pharmacy calls from members, providers, and pharmacies to support medication-related health outcomes. They are responsible for processing prior authorization requests, explaining plan benefits, and assisting with comprehensive medication reviews.
The IRIS Consultant builds relationships with participants to help them navigate long-term care programs and achieve personal goals related to health, housing, and community integration. They are responsible for developing customized care plans, managing budgets, and ensuring compliance with program requirements through regular documentation and participant visits.
The IRIS Consultant builds relationships with participants to help them navigate the Medicaid long-term care program and achieve their personal goals. They are responsible for developing customized care plans, managing budgets, and documenting all activities within the program's data system.
Provides support for care management and coordination activities for members with high-need potential. Develops and monitors care plans while collaborating with multidisciplinary teams to ensure quality and cost-effective member care.
The Senior Specialist drives health plan provider engagement strategies to improve quality outcomes and risk adjustment accuracy through consultative coaching and data-driven action plans. They collaborate with provider practices to address barriers, facilitate training, and ensure alignment with value-based care goals.
The RN will provide oversight, assessment, and guidance to participants in the IRIS Self-Directed Personal Care program. Responsibilities include developing person-centered care plans, conducting home visits, and providing training to participants and care providers.
The investigator is responsible for preventing, detecting, and investigating health care fraud, waste, and abuse through data analysis and medical record reviews. They also prepare referrals for regulatory agencies and law enforcement while ensuring compliance with contractual and federal regulations.
Leads IT service delivery and operations, overseeing service performance, SLAs, budgets, project intake, and alignment of technology services with business needs. Builds stakeholder relationships, drives process and quality improvements, manages escalations, and develops a high-performing team.
The Telephonic Care Manager provides comprehensive care coordination and assessment for high-risk pregnant members within a managed care environment. They develop and monitor individualized care plans while collaborating with multidisciplinary teams to ensure quality and cost-effective outcomes.
The RN will provide oversight, guidance, and education to participants in the IRIS Self-Directed Personal Care program. Responsibilities include conducting assessments, developing person-centered plans of care, and ensuring compliance with program regulations.
The IRIS Consultant builds relationships with participants to help them navigate long-term care programs and achieve personal goals related to health, housing, and community membership. They are responsible for developing customized plans, managing budgets, and documenting all activities within the program's data system.
Provide level II support to members and providers via phone, chat, and email to resolve issues and improve engagement. Document all interactions accurately while meeting performance goals for quality, attendance, and resolution.
The Senior Analyst provides financial support for Medicare lines of business by overseeing performance, forecasting, and medical cost trends. They also evaluate capitation and value-based care arrangements to deliver actionable insights for executive leadership.
The Senior Examiner evaluates claims for incorrect coding, fraud, and processing errors while managing a complex caseload. They also monitor medical treatments and ensure compliance with state and federal regulations.
Provides administrative support to the care management team, including case assignment, member screening, and data entry. Facilitates communication between internal and external stakeholders to ensure effective delivery of member care services.
Leads application engineering teams delivering and supporting cloud-native, AI-enabled solutions on Microsoft Azure for healthcare payer operations, including Medicare and Medicaid programs. Sets architecture and quality standards, oversees implementation and integrations, manages vendor and stakeholder relationships, and develops a team focused on end-to-end business ownership.
Directs and oversees multidisciplinary healthcare services teams including utilization management, care management, and behavioral health programs. Collaborates with senior leadership to establish strategic plans and ensures the delivery of quality, cost-effective member care.
Conducts onsite, virtual, and desktop facility site reviews to ensure compliance with local, state, and federal requirements. Collaborates with providers to offer education, resources, and tools while documenting review outcomes in designated databases.
The Care Manager provides comprehensive care coordination and support for members with high-need potential, including developing care plans and facilitating interdisciplinary team meetings. They are responsible for conducting in-person home visits, monitoring member progress, and ensuring the delivery of quality, cost-effective services.
The Care Manager provides comprehensive care coordination and LTSS-specific activities for members with high-need potential. They are responsible for developing care plans, conducting member assessments, and facilitating interdisciplinary care team meetings to ensure quality and cost-effective outcomes.
The specialist will implement provider engagement strategies to drive quality and risk adjustment outcomes for Tier 2 and Tier 3 providers. They will coach providers, facilitate data exchanges, and manage action plans to improve performance and health outcomes.
The Care Manager provides support for long-term services and supports (LTSS) by coordinating integrated care for members with high-need potential. They are responsible for conducting comprehensive assessments, developing care plans, and monitoring member progress toward desired health outcomes.
The Senior Engineer will design and build enterprise-grade big data solutions on Microsoft Azure to support Medicare/Medicaid operations. They will collaborate cross-functionally to translate business requirements into scalable, AI-driven data architectures.
The IRIS Consultant builds relationships with participants to help them navigate the Medicaid long-term care program and achieve their personal goals. They are responsible for developing customized care plans, managing budgets, and documenting all activities within the program's data system.
The Care Manager coordinates long-term services and supports for members by developing and monitoring individualized care plans. They conduct comprehensive assessments, facilitate interdisciplinary team meetings, and ensure member health and welfare through proactive care coordination.
The Care Manager provides support for LTSS-specific activities and coordinates integrated care for members with high-need potential. Responsibilities include conducting comprehensive member assessments, developing care plans, and facilitating interdisciplinary care team meetings.
The Care Manager provides care coordination and support for members with high-need potential by developing and monitoring comprehensive care plans. They conduct member assessments, facilitate interdisciplinary team meetings, and ensure the delivery of quality, cost-effective services.
Conduct comprehensive member assessments, coordinate waiver enrollment, and develop and monitor individualized care plans with members, caregivers, and healthcare professionals. Coordinate integrated LTSS and behavioral health services, authorize appropriate waiver services, address barriers to care, and support member safety and progress toward goals.
Conduct member assessments, coordinate waiver enrollment, develop and monitor care plans, and authorize appropriate waiver services. Coordinate integrated care with members, caregivers, providers, interdisciplinary teams, and community resources while addressing barriers and preventing critical incidents.
The Care Manager provides comprehensive care coordination and LTSS-specific activities for members with high-need potential. They are responsible for developing care plans, conducting home visits, and facilitating interdisciplinary care team meetings to ensure quality and cost-effective outcomes.
Conduct comprehensive member assessments and coordinate LTSS care, including waiver enrollment, service planning, authorizations, and ongoing monitoring. Collaborate with members, caregivers, clinicians, and interdisciplinary teams to address barriers, integrate services, and support member health, safety, and care goals.
Conduct comprehensive member assessments and coordinate long-term services and supports, including waiver enrollment, service authorization, and individualized care planning. Monitor care plan outcomes, facilitate interdisciplinary collaboration, address barriers to care, and support member health and safety through local visits and ongoing coordination.
Provides diagnosis-related nutrition education and individualized dietary plans, consulting with members, families, physicians, and multidisciplinary teams. Monitors and documents nutritional status and care plan progress, develops success measures, and coaches members toward self-management goals.
The engineer will provide senior-level support for enterprise infrastructure, including cloud environments, automation frameworks, and system reliability. They will collaborate with cross-functional teams to design, deploy, and maintain scalable technical solutions while ensuring compliance with security and industry standards.
Leads and manages a regional team responsible for multi-state delegation oversight activities to ensure compliance with state, federal, and NCQA requirements. Collaborates with internal business owners to manage delegated entity performance, including audits, corrective action plans, and risk monitoring.
Conduct member assessments and coordinate waiver enrollment, care plans, service authorizations, and ongoing monitoring for people with long-term support needs. Collaborate with members, caregivers, providers, and interdisciplinary teams to integrate services, address barriers, and promote member health and progress toward goals.
The Care Manager provides support for LTSS-specific activities and coordinates integrated care for members with high-need potential. They are responsible for conducting comprehensive assessments, developing care plans, and monitoring member progress toward desired health outcomes.
The Care Manager coordinates integrated long-term services and supports for members, developing and monitoring individualized care plans. They conduct comprehensive assessments, facilitate interdisciplinary team meetings, and ensure members receive quality, cost-effective care.
The Director leads and directs teams responsible for planning and implementing healthcare quality improvement initiatives and education programs. They oversee compliance with NCQA accreditation, HEDIS performance improvement, and federal/state quality intervention rules.
Provides support for care management and coordination activities for members with high-need potential across the continuum of care. Develops and monitors care plans while collaborating with multidisciplinary teams to ensure quality and cost-effective member outcomes.
The Care Manager completes comprehensive member assessments and develops integrated care plans to support long-term services and supports. They collaborate with multidisciplinary teams to monitor member progress, authorize services, and ensure quality, cost-effective care delivery.
The Care Manager provides support for LTSS-specific activities and coordinates integrated care for members with high-need potential. Responsibilities include conducting comprehensive assessments, developing care plans, and facilitating interdisciplinary care team meetings to ensure quality outcomes.
The Program Manager provides subject matter expertise to align and implement healthcare services strategies across health plans. They act as a liaison between enterprise and market teams to facilitate communication, manage operational risks, and drive successful program execution.
The Director leads the health plan provider relations team, overseeing network development, provider education, and issue resolution. They collaborate with internal stakeholders to implement strategic network planning and ensure compliance with state and federal regulations.
The IRIS Consultant builds relationships with participants to help them navigate long-term care programs and achieve personal goals related to health, housing, and community integration. They are responsible for developing customized plans, managing budgets, and documenting all activities within the program's data system.
The manager leads the actuarial team in analyzing data to identify risks, establish premium rates, and provide liability estimates. They are responsible for mentoring staff, overseeing formal actuarial reporting, and designing studies related to medical care costs.
The processor facilitates coordination of benefits by validating medical and pharmacy coverage through provider portals and outbound calls. They also maintain internal databases and submit claim adjustments to ensure accurate payment and compliance with regulatory requirements.
Provides non-clinical administrative support to the care management team, including case assignment, data entry, and member scheduling. Facilitates communication between internal and external stakeholders to ensure effective delivery of member care services.
The specialist oversees and implements health plan quality improvement activities to ensure compliance with NCQA, federal, and state regulatory requirements. They are responsible for monitoring quality metrics, conducting medical record audits, and facilitating systemic quality of care investigations.
Leads and directs a multidisciplinary team of healthcare professionals in functions such as utilization management, behavioral health, and care transitions. Ensures integrated delivery of care, regulatory compliance, and the achievement of quality and cost-effective member outcomes.
The VP of Data & Analytics will lead enterprise-wide business intelligence and AI initiatives to improve operational efficiency and member outcomes. They will act as a strategic advisor to executive leadership, building scalable analytics solutions and fostering a data-driven culture across the organization.
The RN will provide oversight, guidance, and education to participants in the IRIS Self-Directed Personal Care program. Responsibilities include conducting assessments, developing person-centered care plans, and ensuring compliance with program regulations.
The RN will provide oversight, assessment, and care planning for participants in the IRIS Self-Directed Personal Care program. Responsibilities include conducting home visits, training care providers, and ensuring compliance with program documentation and regulations.
The Program Manager is responsible for planning and directing project schedules, budgets, and cross-functional teams to support new vendor implementations. They ensure governance standards are upheld while tracking performance metrics and managing program collateral.
The Care Manager coordinates integrated care for members with high-need potential by developing and monitoring comprehensive care plans. They also conduct in-person assessments, facilitate waiver enrollment, and collaborate with multidisciplinary teams to ensure quality and cost-effective outcomes.
The Senior Analyst provides support for advanced provider data management activities, including analyzing business processes and identifying areas for improvement. They also lead cross-functional projects, manage provider databases, and collaborate with stakeholders to translate business objectives into functional specifications.
The Care Manager coordinates long-term services and supports for members, including conducting comprehensive assessments and developing individualized care plans. They facilitate interdisciplinary team meetings and monitor member progress to ensure quality, cost-effective care delivery.
The Corporate Development Manager supports the execution of merger and acquisition transactions and advances the company's inorganic growth strategy. This role involves identifying and evaluating growth initiatives while coordinating due diligence and cross-functional deal activities.
The Pharmacy Services Director provides leadership for health plan pharmacy programs, ensuring quality, cost-effectiveness, and regulatory compliance. They act as a subject matter expert, overseeing utilization management and collaborating with internal and external stakeholders to optimize medication-related health outcomes.
The Care Manager provides care coordination and support for members with high-need potential by developing and monitoring comprehensive care plans. They facilitate interdisciplinary team meetings and conduct assessments to ensure members receive quality, cost-effective services.
The Care Manager provides support for LTSS-specific activities and coordinates integrated delivery of member care across the continuum. They are responsible for completing comprehensive member assessments, developing care plans, and facilitating interdisciplinary care team meetings.
The Senior Representative serves as the primary point of contact for contracted providers, managing network adequacy, provider education, and issue resolution. They are responsible for conducting site visits, ensuring compliance with Molina policies, and fostering partnerships to improve member outcomes.
The Care Manager conducts comprehensive assessments and develops integrated care plans for Medicare members to ensure quality outcomes. They facilitate interdisciplinary care team meetings and perform ongoing monitoring of member progress through telephonic and face-to-face outreach.
The Eligibility Screener conducts face-to-face Adult Long-Term Care Functional Screens for IRIS program participants to determine eligibility. They also coordinate with consultants, agencies, and medical professionals to verify screening results and maintain accurate documentation.
The manager leads the Quality Systems team to execute quality initiatives, manage performance data, and ensure regulatory compliance. They collaborate with cross-functional stakeholders to develop data-driven strategies that improve program performance and address quality care gaps.
The manager will oversee quality performance improvement initiatives and manage data collection strategies to improve health outcomes. They will also ensure compliance with regulatory audit guidelines and collaborate with cross-functional teams to close quality care gaps.
The Care Manager coordinates integrated delivery of care for members with high-need potential by developing and monitoring comprehensive care plans. They also conduct in-person assessments, facilitate waiver enrollment, and collaborate with multidisciplinary teams to ensure quality and cost-effective outcomes.
The Program Manager will lead all phases of the program lifecycle, including planning, execution, and monitoring, while ensuring alignment with business priorities. They will coordinate cross-functional stakeholders, manage program-level risks and dependencies, and report on key performance indicators.
The RN will provide oversight, assessment, and guidance to participants in the IRIS Self-Directed Personal Care program. Responsibilities include developing person-centered care plans, conducting home visits, and providing training to participants and care providers.
The AVP of Infrastructure provides strategic leadership for enterprise infrastructure operations, technology platforms, and engineering across all business lines. They are responsible for shaping the long-term vision, ensuring scalable and secure systems, and managing high-performing teams to drive operational excellence.
Leads and directs a team responsible for medical economics analysis to identify risks, opportunities, and improve financial performance. Collaborates with health plans to track savings and drive trend performance reviews for Medicaid and behavioral health programs.
The nurse is responsible for reviewing medical documentation to ensure medical necessity and appropriate level of care using established clinical guidelines. They also facilitate the review of prospective, retrospective, and concurrent appeals for denied prior authorizations and claims.
The Senior Specialist is responsible for developing and implementing clinical quality member intervention initiatives across various lines of business. They monitor intervention activities, analyze outcomes, and collaborate with community-based organizations to improve health plan quality.
The Eligibility Screener conducts face-to-face Adult Long-Term Care Functional Screens to determine program eligibility for the Wisconsin IRIS program. They also verify screen results with consultants, agencies, and medical professionals while maintaining accurate documentation.
The IRIS Consultant builds relationships with participants to help them navigate the Medicaid long-term care program and achieve their personal goals. They are responsible for developing customized care plans, managing budgets, and documenting all activities within the program's data system.
The Care Manager provides support for LTSS-specific activities and coordinates integrated care for members with high-need potential. They are responsible for conducting comprehensive assessments, developing care plans, and monitoring member progress toward desired health outcomes.
The Care Manager coordinates long-term services and supports for members, developing and monitoring individualized care plans to ensure quality outcomes. They conduct comprehensive assessments, facilitate interdisciplinary team meetings, and provide ongoing support to address medical and psychosocial needs.
Leads and directs the configuration team responsible for the delivery, execution, and maintenance of technical products supporting enterprise operations. Acts as the primary bridge between business stakeholders and technical delivery teams to ensure solutions align with business outcomes and regulatory requirements.
Provides senior-level financial analysis, reporting, and forecasting to support business decisions and the financial management of the IL health plan. Responsibilities include managing the monthly close process, developing financial models, and handling regulatory reporting.
Leads the development and implementation of value-based strategies and programs to improve risk adjustment revenue and financial objectives. Manages a high-performance team and collaborates with leadership to design contracts and monitor performance via internal dashboards.
Provides senior-level support for the intake and interpretation of regulatory and functional requirements related to coverage and reimbursement. Coordinates with stakeholders to translate business needs into application requirements and ensures alignment across health plans.
Provides comprehensive behavioral health assessments and develops integrated care plans for members. Coordinates with multidisciplinary teams and conducts home or telephonic visits to monitor progress and ensure quality care.
Responsible for verifying that clinical services are medically necessary and align with established guidelines and insurance policies. The role involves analyzing service requests, processing prior authorizations, and collaborating with multidisciplinary teams to ensure cost-effective member care.
