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The analyst will identify and document fraudulent or erroneous pharmacy claims, prepare audit reports, and determine overpayments. They will also collaborate with Claims Administration to manage re-billing and ensure compliance with regulatory requirements.
The RN Clinical Care Coordinator manages a panel of members with complex medical and behavioral needs by conducting assessments and developing person-centered care plans. They collaborate with internal teams and community resources to provide education, support care transitions, and advocate for member needs.
Perform skilled physical therapy services including screening, evaluation, and the development of individualized plans of care for pediatric patients. Supervise physical therapist assistants and collaborate with a multidisciplinary team to support the holistic growth of children.
The Supervisor provides programmatic supervision, coaching, and guidance to Family Peer Support Specialists within their assigned region. They are also responsible for managing performance, conducting quality assurance audits, and ensuring contract deliverables are met.
The Clinical Pharmacist will lead prospective clinical review activities for specialty medications and infusions to optimize utilization, affordability, and patient outcomes. They will partner with cross-functional teams to implement medication management strategies and ensure compliance with regulatory and clinical standards.
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Provide clinical training and on-site support to physicians and hospital staff regarding the safe and effective use of medical technology. Manage disposable inventory, document customer interactions, and ensure all procedure-related paperwork and technical support requirements are met.
The Telehealth Coordinator manages inbound and outbound calls in the Virtual Care Center to support patients and providers. Responsibilities include scheduling appointments, processing referrals and authorizations, and providing technical assistance to ensure efficient virtual care delivery.
Review clinical information and apply evidence-based guidelines to support coverage and care decisions. Collaborate with providers and care teams to coordinate appropriate healthcare services and improve care quality.
The technician serves as the primary contact for prior authorization requests from providers and members. They are responsible for determining if requests require pharmacist intervention and maintaining accurate documentation of all outcomes.
The Utilization Management Nurse Consultant reviews clinical information to support coverage determinations and coordinates care plans with interdisciplinary teams. They serve as a clinical resource to ensure high-quality healthcare utilization and effective member-centered outcomes.
The Clinical Operations Supervisor oversees healthcare management staff to ensure high-quality clinical interventions and operational objectives are met. They are responsible for implementing clinical policies, mentoring team members, and managing care plan development to improve patient outcomes.
Conduct comprehensive in-home health evaluations for health plan members, including medication reviews and physical assessments. Provide patient education and bridge gaps in care while maintaining accurate clinical documentation via an iPad.
The consultant will coordinate and document utilization management programs by applying clinical judgment and medical necessity criteria to determine coverage. They will also facilitate appropriate healthcare services for members and collaborate with providers to ensure optimal treatment outcomes.
The Clinical Counselor provides on-demand single session consultations, clinical assessments, and triage services to members via phone, video, or chat. They leverage technology platforms to ensure timely, high-quality mental health support and connect members to appropriate resources.
The Clinical Counselor provides on-demand single session consultations, clinical assessments, and triage services to members. They utilize various communication modalities including video, live chat, and phone to deliver timely mental health support.
The Utilization Management Nurse Consultant reviews and assesses clinical information to support coverage determinations and care decisions. They collaborate with interdisciplinary teams to coordinate treatment plans and identify opportunities for improved healthcare quality and member outcomes.
The Case Manager is responsible for conducting comprehensive in-home assessments and developing person-centered care plans for dual-eligible Medicare and Medicaid members. They coordinate services across interdisciplinary teams to ensure members receive appropriate community-based support while maintaining regulatory compliance.
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The Clinical Counselor provides on-demand mental health consultations, clinical assessments, and triage services via phone, video, or chat. They leverage technology platforms to connect members with appropriate mental health solutions to ensure timely and effective care.
The Sr Analyst will provide consultative support and medical cost-based analysis to identify utilization and unit cost drivers. They will collaborate with network and clinical management to develop strategic initiatives that improve the company's discount position and patient care outcomes.
The Utilization Management Nurse Consultant reviews clinical information to support coverage determinations and coordinates healthcare services across the continuum of care. They collaborate with providers and care teams to facilitate appropriate treatment planning and identify opportunities to improve member outcomes.
The Lead Clinical Application Specialist delivers high-quality clinical training and workflow configuration for advanced imaging solutions to clinicians at hospitals and cancer centers. They serve as the primary onsite expert during deployments, ensuring alignment with quality systems and providing ongoing customer support.
The Associate Medical Director is responsible for conducting clinical case reviews and making medical necessity determinations for DME services. They also facilitate physician-to-physician calls and ensure consistent application of medical policies across the organization.
The Burn Registrar is responsible for categorizing, coding, and interpreting patient medical records to ensure accurate data submission into clinical registries. They also contribute to team best practices and identify process improvement opportunities to streamline data abstraction tasks.
The Sessional Lecturer will facilitate a professional graduate course on health data governance using competency-based learning and assessment methods. The role requires active engagement with students during online synchronous sessions and availability for student support outside of class hours.
The Utilization Management Registered Nurse interprets and supports the coordination, documentation, and communication of medical services and benefit determinations. They manage post-acute care services to ensure members receive the appropriate level of care in the most suitable setting.
The specialist is responsible for requesting and obtaining medical records from healthcare providers to ensure accurate documentation and risk-adjusted revenue. They must coordinate retrieval methods, maintain secure repositories, and adhere strictly to HIPAA regulations.
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The Scientific Leadership Research Coordinator manages clinical trial operations, including investigator-initiated studies and scientific congress logistics. They also support the development of scientific and medical affairs strategies through collaborative engagement with stakeholders.
The Clinical Pharmacist will manage medication therapy for high-risk patients with chronic conditions and collaborate with a multi-disciplinary team to optimize patient outcomes. Responsibilities include conducting medication reconciliations, providing disease state education, and supporting quality measures within the clinic's EMR system.
The Property Adjuster is responsible for investigating property claims, inspecting damages, and preparing accurate estimates within their designated authority. They also manage claim files, negotiate settlements, and coordinate with agents and legal counsel as necessary.
The Vice President of Healthcare Economics will lead enterprise strategies to manage total cost of care and design the next generation of healthcare value creation. This role involves directing population health analytics, establishing affordability targets, and leading cross-functional teams to drive measurable outcomes.
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