Researches the substance of complex appeal or retrospective review requests including pre pay and post payment review appeal requests. Provides thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines. Documents decisions within mandated timeframes and in compliance with applicable regulations or standards. Perf

The Community Well Care Coordination Manager must oversee the care coordination, complex case management functions for PathWays to Aging members who live in the community and who are not receiving Home and Community Based Services (HCBS) or designated as Nursing Facility Level of Care (NFLOC). The Care Coordination Manager must, at a minimum, be a registered nurse or simil

Data Entry (Intake) enters information in system from fax system verifies eligibility, coverage, request for missing information, redirecting to in network facilities, assist in phone queue questions . Correspondence Letter generation selects correct template, minor grammar checks . Required Education High School Graduate (CRP); Some College (Correspondence Processor) Req

All UM standard Inpatient, Outpatient and Custodial Care processes and workflows for any requests, verbal notifications for denials/partial denials to both member and provider, participation in IDTs, personal queue management and clinical reviews. Must Have Skills Must have experience in UM, experience with Turnaround Timeframes, good with computer systems and be able to

Seeking an RN Care Manager with experience working with high risk OB members to perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members. This position is fully remote. The work schedule is M F 8 00am 5 00pm. You MUST be a Licensed RN that is good standing and residing in t

Schedule appointments, gather medical histories and updated member and provider information in support of member outreach and claims reimbursement. Essentials Understanding of basic medical terminology Call center experience Good customer service skills Ability to problem solve basic computer issues Managing Excel spread sheets Work with multiple computer system Good verb

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, obtai

Performs routine facility maintenance tasks to ensure company employees have a safe and properly conditioned work environment. Assemble, relocate, and repair free standing or modular office furniture and equipment. Perform general maintenance tasks. Clean equipment, mechanical rooms, and work sites as directed. Perform preventative inspections. Respond to emergency calls

Seeking a Registered Nurse with current in state license, with Utilization review or quality management experience. This position is fully remote. Work schedule is Mon Fri, 8 00am 5 00pm. Must have at least 3 years' experience in a clinical setting. InterQual experience desired. Must have basic PC skills, beginner knowledge of Microsoft Word and Excel.

UAS Certified RN licensed in the state of NY. Conduct face to face assessments of members' functional status, medical, behavioral, psychosocial and community resource needs. Provides the Interdisciplinary Care Team (ICT) with assessment information and acts as facilitator to ensure that members' needs are met. Develop an ICP/PCSP based on members' clinical, behavioral, an

A customer service representative, or CSR, will act as a liaison, provide services information, and resolve any emerging problems that our customer accounts might face with accuracy and efficiency. The best CSRs are genuinely excited to help customers. They're patient, empathetic, and passionately communicative. They love to talk. Customer service representatives can put

Job Title Customer Service Advocate I Location Remote (Indiana) Hours 11am 8pm Monday Friday (Eastern Standard Time Zone) Job Description Serves as the first line advocate that focuses on resolving inquiries, issues, or concerns for members and/or providers. Leverages a variety of communication channels to provide members and/or providers with timely, accurate, and persona

The Clinical Appeals Nurse is responsible for the completion of clinical appeals and state hearings from all states. Essential Functions Responsible for the completion of clinical appeals and state hearings from all states Review and complete all provider clinical appeals within required timeframes. Review and complete member clinical appeals within required timeframes. Re

Manage administrative intake of members Work with hospitals, clinics, facilities and the clinical team to manage requests for services from members and/or providers Process incoming and outgoing referrals, and prior authorizations, including intake, notification and census roles Assist the clinical staff with setting up documents/triage cases for Clinical Coverage Review

Responds to customer questions via telephone and written correspondence regarding insurance benefits, provider contracts, eligibility and claims. Analyzes problems and provides information/solutions. Operates a PC/image station to obtain and extract information; documents information, activities and changes in the database. Thoroughly documents inquiry outcomes for accura