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Direct activities of the Utilization Management staff. Oversee staff performance with regard to prior authorization, medical necessity determinations, concurrent review, retrospective review, continuity of care, care coordination, and other clinical and medical management programs. These responsibilities extend to physical and behavioral health care and transportation services. Ensure effective da
Posted 6 days ago
Under the direction of the unit Supervisor, the Clinical Care Reviewer is responsible for completing medical necessity reviews. Using clinical knowledge and nursing experience, the nurse reviews provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review. It is within the nur
Posted 6 days ago
Under the Direction of the Supervisor, the Transition Care Manager is responsible for completing preventative multidisciplinary discharge planning for plan member presenting to the Emergency Room and / or Acute Setting using Plan policies and procedures. The Transition Care Manager will assess and processes discharge planning needs across all disciplines including necessary case management referra
Posted 14 days ago
Under the general supervision of the Supervisor, Utilization Management, this position screens calls from members and providers providing information to members regarding the accessing of care and assisting providers in the authorization process. Screens information received and refers members to the appropriate provider and/or contacts the provider directly for members. Facilitates the authorizat
Posted 1 month ago
Under the supervision of the Manager for Utilization Management, this position is responsible for providing daily oversight of UM Nurses, UM Technicians and staff members within Utilization Management. Responsibilities include providing clinical, technical and operational support and direction, including organization and monitoring of all medical services. Responsible for direct supervisory oversi
Posted 1 month ago
Direct activities of the Utilization Management staff. Oversee staff performance with regard to prior authorization, medical necessity determinations, concurrent review, retrospective review, continuity of care, care coordination, and other clinical and medical management programs. These responsibilities extend to physical and behavioral health care and transportation services. Ensure effective da
Posted 1 month ago
Under the direction of the unit Supervisor, the Clinical Care Reviewer is responsible for completing medical necessity reviews. Using clinical knowledge and nursing experience, the nurse reviews provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review. It is within the nur
Posted 1 month ago
Reporting directly to the Manager of Community Education, this position is responsible for the supervision of Community Educators in their assigned territories. Responsible for the day to day management of the Community Educators' outreach activities as well as weekly schedules, field monitoring and trainings. Assists management in the implementation of strategic outreach plan to help achieve comp
Posted 1 month ago
As part of the Quality Management team, the Quality Performance Specialist Senior is responsible for leading and coordinating the clinical quality review process of member concerns and medical records utilizing of care standards. In addition, responsibilities also include supporting the annual medical record review activities including HEDIS and, Clinical Practice Guidelines. The position also sup
Posted 1 month ago
Under the supervision of the Rapid Response Outreach Supervisor, the incumbent will provideselect program interventions according to established health management program guidelines and the member population.With direction from the program's Case Manager or Supervisor/Manager, the Care Connectorwill screen identified members based on plan stratification for the program. The Care Connector interact
Posted 1 month ago
Under the supervision of the Supervisor of Integrated Care Management, the Prenatal Care Manager RN assists members appropriate for care coordination andcare management services in achieving their optimal level of health. The PrenatalCare Manager RN is responsible for engaging the pregnantmember and providers to assess, plan and establish individual member goals. Will facilitate and coordinate car
Posted 2 months ago
As part of the Quality Management team, the Quality Performance Specialist RNis responsible for leading and coordinating the clinical quality review process of member concerns and medical records utilizing of care standards. In addition, responsibilities also include supporting the annual medical record review activities including HEDIS and, Clinical Practice Guidelines. The position also supports
Posted 5 months ago
Responsible for managing the day to day activities of the Network Management department and staff related to alternative reimbursement models Responsible for assisting the Leader with departmental activities related to provider satisfaction, education, and communication. This position is also responsible for tracking all performance metrics and analysis of contract performance. Also updates and ma
Posted 7 months ago
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