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Director, Case Management (Medicare) (1079274) Position Purpose Responsible for defining and directing a complete Case Management Program in conjunction with corporate goals and objectives Direct the overall operational leadership of case management functions and staff Perform and oversee needs analysis and planning Work with executive leadership to ensure targets are met for the annual operating
Posted Today
Customer Service Representative I (1079636) 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 5 days ago
Manager, Medical Management (Medicare) (1076038) Position Purpose Responsible for managing a complete program of medical management in accordance with the mission, philosophy, and objectives of plan. The position has oversight for the functions of utilization management and case management. Implement changes to medical service functions and performance in relation to company mission, philosophy ob
Posted 7 days ago
Pharmacy Coordinator (1079560) Position Purpose Perform duties to support the efforts pharmacy department in the development, coordination and maintenance of the health plan's pharmacy program. Receive and respond to provider and pharmacy calls regarding the prior authorization and formulary process Perform review of pharmacy and override process in compliance with pharmaceutical related company a
Posted 8 days ago
Prior Authorization Nurse I (1072827) Position Purpose Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests. Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward request
Posted 16 days ago
Manager, Clinical Pharmacy Services (1068677) Position Purpose Oversee the clinical pharmacy services function and develop new quality improvement and revenue enhancement activities Ensure all prior authorization requests are reviewed and completed accurately and timely Assist with prior authorizations and determinations for appropriate drug products for complex or escalated requests Research and
Posted 16 days ago
Clinical Pharmacist (1078084) Position Purpose Define and develop standard and custom formularies for assigned plan. Develop clinical criteria for review of medications, recommend plan design changes and communicate recommendations to clients Monitor and review prior authorization requests for medications Develop and design clinical edits to adjudicate claims and enhance drug utilization Analyze p
Posted 16 days ago
Make outbound calls and provide information and education regarding program features and requirements Gather and verify demographic information Document calls, ensure completion and accuracy and submit reporting to management Gather information and encourage callers to perform a specific action based on the needs of the call campaign Identify barriers being experienced by callers and solve any iss
Posted 19 days ago
Health Net
- North Charleston, SC
Perform duties to ensure HEDIS data accuracy and reporting, including investigation, auditing, and improvement opportunities. Assist with quality improvement initiatives in the service and clinical areas. Coordinate, complete, and update management on clinical quality metrics and HEDIS processes and results Establish and maintain an action plan to improve HEDIS scores Implement process to request
Posted 21 days ago
Customer Service Representative I (1060455) 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 22 days ago
Health Net
- North Charleston, SC
Clinical Nurse Liaison (1078419) Position Purpose 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
Posted 22 days ago
Senior Trainer (Clinical) RN (1076027) Position Purpose Develop, conduct, administer and analyze clinical training programs, conduct audits of clinical systems entry and/or processes, and assist in development of audit tools Develop and conduct clinical education courses, including case management education and training for new employees Develop and maintain complex audit processes and audit tools
Posted 29 days ago
Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities. Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, co
Posted 29 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 29 days ago
Behavioral Case Manager (Columbia, SC Office Based) (1076423) Position Purpose Perform duties related to the day to day operations of the High Risk 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. Assess members' current functional level and, in collaboration with the member, develop a
Posted 1 month ago
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