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Medical Management Auditor (Office Based) Medical Management Auditor (Office Based) (1113826) Position Purpose Responsible for the auditing of corporate, health plan, and specialty company staff related to clinical systems entry and/or processes Develop and maintain the audit process and tools related to authorizations, appeals, quality events, and case management in CCMS; interrater reliability r
Posted Today
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 1 day ago
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 Family Centers, Guard and Reserve programs (including Inter Se
Posted 4 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 4 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 6 days ago
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 concerning military connected children to service members and or child development center or school staff. Direct non clinical services to children an
Posted 7 days ago
Sales Representative (Medicare) Columbia, SC Sales Representative (Medicare) Columbia, SC (1112825) Position Purpose Provide sales coverage and develop bestpossible market penetration for all products to present to prospective membersin assigned territory in accordance with company policies and programs. Providegreater access to health insurance , by providing education andassistance to Medicare e
Posted 8 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 10 days ago
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 requests to the appropriate Physician or Medical Director with
Posted 13 days ago
Leading a team of Clinicians including utilization review oversight of clinical services, marketing of clinical services and supervision and development of clinical staff. Qualifications Education/Experience Master's degree in BCBA (Board Certified Behavior Analyst) and independent BCBA/BCBA D licensure required. A minimum of 3 5 years ASD specific case and/or utilization management and/or ABA wor
Posted 13 days ago
Manage Case Management and Care Coordination services and activities for members with co occurring behavioral health and medical conditions. Manage clinical team of licensed medical and behavioral health clinicians. Manage clinical services including oversight of clinical policies and procedures and daily activities of integrated care coordination team staff. Ensure adequate staffing to conduct ca
Posted 13 days ago
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 14 days ago
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 14 days ago
Responsible for developing and conducting a variety of training programs and auditing tools for various health plans. Training staff on all aspects of Medicare, Medicaid, Marketplace and various health plans. Coordinate training efforts with various cross functional areas Develop and administer a universal training curriculum, employ technologies and enhance training development programs Conduct t
Posted 19 days ago
Resolve customer inquiries via telephone and written correspondence in a timely and appropriate manner. Using current reference materials, answer inquiries from members and/or providers regarding claims, eligibility, covered benefits, authorizations and pharmacy related matters Provide assistance to members and/or providers regarding website registration and navigation Educate members and/or provi
Posted 19 days ago
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