Oversees the delivery of high-quality healthcare and adherence to utilization standards for UPMC Health Plan members. Leads provider credentialing, quality improvement goals, and the review of medically pressing issues and member grievances.
UPMC
20 Remote Job Openings at UPMC
The specialist analyzes medical claims to determine eligibility for leave and disability benefits while managing the full lifecycle of absences. They provide guidance to employees and managers on policies and deliver training and mentoring to peers.
Manage behavioral health and minor medical disability cases by coordinating leave processes and determining claim approvals. Collaborate with healthcare providers and employees to monitor treatment plans and facilitate return-to-work efforts.
The Leave Specialist provides administrative support for employee leave requests, advising staff and managers on policies such as FMLA and military leave. They are responsible for tracking absences, coordinating with payroll and disability specialists, and managing all communications throughout the leave process.
The UM Care Manager performs utilization reviews of health plan services and assesses member barriers to care to ensure cost-effective delivery. They collaborate with medical directors and providers to determine medical necessity and coordinate appropriate discharge plans.
Serve as the first point of contact for prospective Medicare Advantage members by answering inbound calls and educating them on plan options. Support the sales team through outbound outreach and assist individuals with the enrollment process over the phone.
The Telephonic Care Manager provides care coordination and health education for adult Health Plan members via telephone. They develop comprehensive care plans to address medical, behavioral, and social needs while collaborating with providers and caregivers.
The specialist facilitates modifications to clinical documentation through interaction with physicians to ensure appropriate clinical severity is captured. They are responsible for the daily evaluation of medical records and presenting trended data to healthcare teams.
Manage a caseload of Community HealthChoices participants by providing telephonic care coordination and health education. Develop comprehensive care plans to close gaps in preventive care and reduce unnecessary hospital readmissions.
Serve as the first point of contact for patients to schedule appointments and provide guidance on preparation and registration. Responsible for verifying patient demographics and insurance information while maintaining data integrity in the system.
Perform utilization reviews and clinical assessments to ensure members receive covered services in the most cost-effective and appropriate settings. Coordinate with providers and medical directors to facilitate safe transitions of care and coordinated discharges from inpatient settings.
The Telephonic Care Manager provides care coordination and health education to members via telephone to address medical, behavioral, and social needs. They develop comprehensive care plans to close gaps in preventive care and reduce unnecessary hospital readmissions.
Supervise a team of Hospital Billing claims analysts and provide technical guidance on claims and remittance administration. Collaborate with revenue cycle operations to apply corrections to claim edits and coordinate regulatory updates and Epic upgrades.
Manages and monitors budgets and expenditure activities for funded sponsored projects in accordance with university and sponsor regulations. Provides financial reports, analyzes account balances, and ensures compliance with administrative award terms.
Review physician and nursing documentation to assign accurate ICD and CPT codes for ENT services. Manage coding edits, denials, and physician queries to ensure optimal reimbursement and compliance.
Responsible for assigning accurate ICD-10 and CPT codes for same-day surgery and observation cases to ensure proper reimbursement. Duties include reviewing documentation for completeness, reconciling NCCI edits, and formulating physician queries for clarification.
Physician Educator HPL- Remote- Clearfield County, PA & Surrounding Area!
UPMC
·
Full Time
·
a month ago
UPMC
The Physician Educator serves as a liaison between the Health Plan and participating providers, focusing on education related to coding and documentation. Responsibilities include assessing learning needs, implementing strategic plans, and providing feedback to improve coding practices.
The specialist is responsible for the investigation, evaluation, negotiation, and disposition of assigned workers' compensation lost time claims. They will also manage litigation activities, budgets, and claim outcomes while ensuring compliance with company policies and state regulations.
The Medical Physicist will oversee dosimetrists to ensure accurate treatment plans and collaborate with the Radiation Oncologist for treatment planning and delivery. Key duties include developing quality control programs, ensuring equipment functionality through precise measurements, and maintaining regulatory compliance.
The Lost Time Claims Specialist II is responsible for the analysis, investigation, evaluation, negotiation, and disposition of assigned claims. They will manage litigation activities and ensure claims are processed according to company policies and best practices.
