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Referral Specialist I (1107008) Position Purpose Assist in monitoring utilization of medical services to assure cost effective use of medical resources through processing prior authorizations. Initiate authorization requests for outpatient and inpatient services in accordance with the prior authorization list. Route to appropriate staff when needed. Verify eligibility and benefits Answer phone que
Posted 1 day ago
Customer Service Representative I (1109119) Position Purpose Respond to customer inquiries via telephone and written correspondence in a timely and appropriate manner. Respond to telephone or written correspondence inquiries from members and/or providers within established timeframes utilizing current reference materials and available resources Provide assistance to members and/or providers regard
Posted 2 days ago
Health Net
- North Charleston, SC
Serve as a liaison for external groups and providers regarding clinical information from the Operations and Medical Management teams Implement and manage procedures for tracking, identifying and problem solving operational issues Interpret and present program results and develop data driven analysis and metrics used to measure effectiveness and ROI of all current and new products Act as the clinic
Posted 2 days ago
Health Net
- North Charleston, SC
Serve as a liaison for external groups and providers regarding clinical information from the Operations and Medical Management teams Implement and manage procedures for tracking, identifying and problem solving operational issues Interpret and present program results and develop data driven analysis and metrics used to measure effectiveness and ROI of all current and new products Act as the clinic
Posted 2 days ago
Outbound Services (LPN) (1105046) Position Purpose Provide information and scripted education for inbound and outbound calls; perform duties and responsibilities related to the various outbound call programs such as Health Risk Screenings. Under the direction of a registered nurse perform health risk screenings; provide scripted health education to callers; participate in other health related tele
Posted 3 days ago
Military Family Life Counselor MFLC (1109054) Position Purpose This description should be used exclusively with the SPA Salary Structure. The Counselor is a licensed mental health professional who exercises discretion and independent judgment to provide appropriate information, coaching, training, and education to Service Members and their families. Partners with and augments activities of Service
Posted 3 days ago
Develop clinical knowledge and skills by learning about various processes and functions within the Managed Care industry Observe processes and shadow preceptors to gain hands on experience and become familiar with various clinical services Follow instructions and procedures provided by preceptor or manager in accordance with company guidelines Qualifications Observe preceptors and participate in v
Posted 10 days ago
Care Manager I (RN) (1098396) Position Purpose Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past an
Posted 10 days ago
Care Manager II (RN) (1107200) Position Purpose Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care. Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treat
Posted 14 days ago
Care Manager I (RN) (1107426) Position Purpose Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past an
Posted 14 days ago
Perform duties related to the day to day operations of the Integrated Case Management functions to include working with members identified as high risk to identify needs and goals to achieve empowerment and improved quality of life for both behavioral and physical health issues. Assess members' current functional level and, in collaboration with the member, develop and monitor the Case Management
Posted 14 days ago
Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to emergent/urgent and continued stay reviews. Perform onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician
Posted 15 days ago
Medical Director BH (Board Certified Psychiatrist) (1105035) Position Purpose Assist the VP of Clinical Programs to direct and coordinate the physician component of the utilization management functions for the health plan business units. Provides medical leadership for utilization management activities and medical review activities pertaining to utilization review, quality assurance, medical revie
Posted 18 days ago
Special Investigation Unit Investigator (1105856) Position Purpose Investigate allegations of potential healthcare fraud and abuse activity. Assist in planning, organizing, and executing claims investigations or audits that identify, evaluate and measure potential healthcare fraud and abuse. Conduct investigations of potential waste, abuse, and fraud Document activity on each case and refer issues
Posted 27 days ago
Care Manager II (RN) (1103515) Position Purpose Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care. Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treat
Posted 1 month ago
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