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Perform and lead various analysis and interpretation to link business needs and objectives for assigned function and implement process improvements. Lead the support of business initiatives through data analysis, identification of implementation barriers and user acceptance testing of various systems Lead the identification and analysis of user requirements, procedures, and problems to improve exi
Posted 5 days ago
Perform duties to conduct and manage the day to day operations of the case management functions communicating with departmental and plan administrative staff to facilitate daily department functions. Review analyzes of activities, costs, operations and forecast data to determine progress toward stated goals and statistical/financial purposes. Promote compliance with federal and state regulations a
Posted 6 days ago
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 queues and process faxes within established standard
Posted 12 days ago
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 and State guidelines Track and trend overrides to
Posted 28 days ago
Develop, implement, and perform compliance auditing, monitoring and reporting activities based on established program, policies, and practices to ensure and maintain compliance with federal, state, and local regulatory and contractual requirements. Develop and maintain quality and compliance reports and dashboards Review and analyze deliverables and data reports to ensure timeliness of submission
Posted 28 days ago
Direct and coordinate the medical management, quality improvement and credentialing functions for the assigned business unit based on, and in support of the strategic plan, establishing the strategic vision and attendant policies and procedures. Serves as clinical advisor to and educator of medical management staff making sure correct clinical judgment is applied to all medical management determin
Posted 1 month ago
Perform provider data management related activities based on plan and contract specifications and standard business rules includes data analysis and entry, review of data via internet sites and other systems, and usage of multiple systems and applications to validate data is complete and accurate. Enroll providers and practitioners into the provider data management system Update provider and pract
Posted 1 month ago
Centene Corporation
- Columbia, SC / North Charleston, SC
Identify special needs members through the completion of health screens and other resources Work with community outreach/member advocates to coordinate member care Educate providers and community resources on program components and available support services Educate members with special needs to foster compliance with program and positively impact outcomes Conduct site visits as appropriate for pr
Posted 2 months ago
Perform health plan provider orientations and conduct ongoing educational outreach with a focus on improving quality and financial outcomes within the provider network. Act as liaison between providers and the health plan to enhance the business relationship. Conduct initial provider orientations as well as ongoing educational outreach Educate providers regarding policies and procedures related to
Posted 2 months ago
Perform duties to authorize and review utilization of mental health and substance abuse services provided in inpatient, outpatient and intermediate care settings, provide and/or review intakes and initial evaluations, brief focused treatment interventions, monitor quality of care, collect and analyze utilization and cost of care data, assist with discharge planning, arrange transportation; provide
Posted 2 months ago
Manage the compliance department functions, including but not limited to, periodic monitoring and auditing activities based on established compliance program, policies, and practices to ensure and maintain compliance with federal, state, and local regulatory, contractual and legal requirements. Manage approval and submission of timely and accurate contract and regulatory required report deliverabl
Posted 3 months 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 3 months ago
Perform duties to direct and coordinate the medical management, quality improvement and credentialing functions for the assigned health plan based on, and in support of the company's strategic plan; establishing the strategic vision and attendant policies and procedures. Direct and coordinate activities of department and aid the chief officer of the health plan and appropriate corporate staff in f
Posted 4 months 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 5 months 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 6 months ago
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