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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 12 days ago
Thoroughly understands the managed care philosophy and the company's products. Is familiar with the Plan's network providers. Receives, records, and resolves member complaints and problems. Answers calls in a pleasant and courteous manner within 30 seconds. Routinely accesses member information via the computer system. Accurately documents member contacts on the computer system. Responsible for en
Posted 18 days ago
Under the direct supervision of the Operations Supervisor, is responsible for responding in a timely, professional and courteous manner to all customer (member, provider and other customers) inquiries. This includes inbound and outbound member and/or provider phone calls or correspondence regarding benefit, eligibility or customer issues. Makes outreach welcome calls to new members and conduct Hea
Posted 18 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 18 days ago
The Finance department supports the company's financial goals by ensuring budget and cost containment targets are met and on track throughout the year. The interns responsibilities will support the department's goals for budget adherence to G&A targets, cost containment, and revenue maximization. Under the oversight of the Finance Director and Finance Manager, the intern's main responsibilities wi
Posted 18 days ago
The goal of the medical management program is to promote the efficient provision of quality health care services appropriate to the needs of the individual member and to fully integrate physical and behavioral health care services so as to minimize fragmentation in service delivery. The role of the prospective intern will be to support efforts of the Regional (multi state) Medical Management Divis
Posted 19 days ago
The Provider Network Intern will interactwith all team members of PNM. The Intern will gain/enhance knowledge of MCO Plan operations, provider specialties, contractual issues and Select Health mission. Assist with the planning, delivery, and compilation of Provider survey data. Must be professional in communication via email and telephone with provider offices. Requirements Solid computer skills
Posted 24 days ago
Responsible for research and analysis related to provider claims issues. Identifying systematic and procedural issues resulting in claims processing errors and initiating action to resolve those issues. Responsible for ensuring the Plan stays in compliance with the provider contracts. Research State Rules and Regulations, surrounding the CMS Programs and ensures the Claims system is configured ac
Posted 25 days ago
Position is responsible for coordinating and maintaining relationships with community organizations to further promote and strengthen community relations. Develops, implements and manages community event opportunities and coordinates these activities with Marketing/Health Benefits Education staff. Assists in Marketing activities at health fairs and at other special events educating members and pot
Posted 25 days ago
The primary purpose of the job is to be responsible and accountable for the successful, ongoing development, refinement, implementation, measurement, ongoing quality improvement and effectiveness of the Health Plan's, Line of Business or Product's Quality Management Program. Works directly with Senior Executives to plan, organize and direct the identification, prioritization and implementation of
Posted 1 month ago
The Compliance Intern will be responsible for working with the Compliance Director, Compliance Manager and Compliance Specialist with Compliance Director oversight to facilitate compliance activities which may include, but not be limited to the following researching federal and state regulations and statutes and analyzing applicable impact to the plan and contract requirements; drafting training d
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 2 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 4 months ago
Under the supervision of the Supervisor for Utilization Management, this position is responsible for completing medical necessity reviews by using clinical knowledge and nursing experience. Requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review Pend requests for additional infor
Posted 6 months ago
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