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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 or Medical Director with recommendations for other determinations Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Direc
Posted 1 day ago
Assist in activities related to the medical and psychosocial aspects of utilization and coordinated care. Initiate authorization requests for output or input services in keeping with the prior authorization list. Research claims inquiry specific to the department and responsibility. Perform tasks necessary to promote member compliance such as verifying appointments, obtaining lab results. Assess a
Posted 1 day ago
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 pharmacy cost of care, trends, and coordinate th
Posted 1 day ago
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 and present treatment plan and services, prognosi
Posted 6 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 8 days ago
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 or Medical Director with recommendations for other determinations Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Direc
Posted 8 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 8 days ago
Assist in activities related to the medical and psychosocial aspects of utilization and coordinated care. Initiate authorization requests for output or input services in keeping with the prior authorization list. Research claims inquiry specific to the department and responsibility. Perform tasks necessary to promote member compliance such as verifying appointments, obtaining lab results. Assess a
Posted 9 days ago
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, treatment and provider options Utilize assessment ski
Posted 9 days ago
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 and present treatment plan and services, prognosi
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
Centene Corporation
- Columbia, SC / North Charleston, SC
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 and present treatment plan and services, prognosi
Posted 15 days ago
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 Family Centers, Guard and Reserve programs (including Inter Service Family Assistance Committees), unit family support staff officers, an
Posted 20 days ago
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 Family Centers, Guard and Reserve programs (including Inter Service Family Assistance Committees), unit family support staff officers, an
Posted 20 days ago
Perform credentialing and related activities based on plan specifications Perform credentialing and re credentialing activities according to plan specifications and in compliance with NCQA standards Communicate with professionalism with physicians, office managers, providers, and other third parties to secure needed information Gather information for Credentialing Committee meetings Process, track
Posted 23 days ago
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