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Reporting to the Director, Enterprise Accreditation Programs, the Enterprise Accreditation Programs Manager has corporate responsibility for accreditation (health plan and multicultural health care) for all Medicaid, Medicare and Long Term Services and Support plans. In addition to supporting the NCQA activities for the enterprise related to utilization management, behavioral health, population he
Posted 4 days ago
The Care Coordinator (RN/SW) assists members appropriate for care coordination and case management services in achieving their optimal level of health. The Care Coordinator (RN/SW) must have relevant experience and education to work with Enrollees with complex health, behavioral health, long term services and supports and/or psychosocial needs and perform the following functions Provides access to
Posted 6 days ago
The Care Coordinator (RN) assists members appropriate for care coordination and case management services in achieving their optimal level of health. The Care Coordinator (RN) must have relevant experience and education to work with Enrollees with complex health, behavioral health, long term services and supports and/or psychosocial needs and perform the following functions Provides access to a sin
Posted 6 days ago
The Care Coordinator (RN) assists members appropriate for care coordination and case management services in achieving their optimal level of health. The Care Coordinator (RN) must have relevant experience and education to work with Enrollees with complex health, behavioral health, long term services and supports and/or psychosocial needs and perform the following functions Provides access to a sin
Posted 6 days 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 6 days ago
Responsible for the preparation of case management files for assigned Plan members who are eligible to receive Supplemental Security Income (SSI) or CSHCS benefits and the creation and maintenance of case management documentation in the CSHCS/SSI database. Coordinates with the Manager of the DAP and the UM associates to receive monthly data loads and distribute member data to UM for process of ren
Posted 11 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
Manage the day to day activities of the Provider Network Management Medicare staff for the Medicare Medicaid product in South Carolina. Position is the key contact for collaboration with large hospital systems for Medicare contracts. Recruit, negotiate, contract and service all physicians, nursing facilities, hospitals, Home and Community Based Services (HCBS), and ancillary providers and ensure P
Posted 28 days ago
The Personal Care Connector (PCC) is a high touch, extremely effective service specialist, responsible for supporting the daily operations of Medicare Member Services (Personal Service Program), integrated care management, and utilization management program interventions. The PCC performs in a contact center environment, effectively handling calls from Members, Providers and other areas, internal
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 4 months ago
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