Answer incoming phone calls from prospective members, identify the type of assistance and information the customer needs with the goal to convert caller to a qualified lead and sale Follow up with members on questions or to review current or new products and services Navigate multiple computer systems to document member information while maintaining active listening and e

Serve as primary care manager for high medical risks / needs members with comorbid behavioral health needs Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic (SDoH) needs Develop and implement individualized, person centered care plans inclusiv

Perform individual case review for appeals and grievances for various health plan and insurance products, which may include PPO, ASO, HMO, MAPD, and PDP. The appeals are in response to adverse determinations for medical services related to benefit design and coverage and the application of clinical criteria of medical policies Perform Department of Insurance/Department of

Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medicati

Assess, plan and implement care management interventions that are individualized for each member and directed toward the most appropriate, least restrictive level of care Identify and initiate referrals for both healthcare and community based services; including but not limited to financial, psychosocial, community and state supportive services Develop and implement care

Perform audit and risk surveillance activities in accordance with IIA audit standards and the Internal Audit & Advisory Services Charter Executes Internal Audit's segment specific strategies and framework for data enabled Key Risk Indicators (KRI) and Continuous Auditing (CA) by determining and documenting relevant management metrics and mitigating controls for top risk a

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, at least restrictive level of care Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact

Create a positive experience and relationship with the member Help member set goals and develop a care plan to achieve those goals Proactively engage the member to manage their own health and healthcare Support the member to improve their wellbeing by staying out of the hospital, and attend regular visits to their primary physician As needed, help the member engage with m

Consult with users and technology specialists to define business processes and be the liaison between the two parties Perform Business Analysis Ability to define project objective, scope, write business and technical requirements Business Liaison to refine business requirements Communicate and validate requirements with stakeholders Validate solution meets business needs

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Identify potential health care business customers Develop business relationships with agents and/or brokers to increase sales Promote sales of health care and ancillary products to Mid Market Employers through brokers. This includes educating and keeping brokers up to date on products and pricing, evaluating, and discussing with brokers, developing recommendations on whic

Acts as primary CAHPS Manager Collaborating with leadership, develop and drive tactical plan that can be leveraged across the enterprise to achieve CAHPS goals Manages vendor relationships to support CAHPS program Analyzes key KPI's and data to derive progress and opportunities for improvement Establishes and reviews performance metrics on a regular basis to ensure effort

Serve as primary care manager for high medical risks / needs members with comorbid behavioral health needs Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic (SDoH) needs Develop and implement individualized, person centered care plans inclusiv

Telecommute Healthcare Advocate

Telecommute CDI Specialist (St. Louis, MO)