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Knowledge of accreditation standards for managed care organizations, e.g., NCQA, and Federal, State, and local requirements for FQHC and managed care organizations preferred.
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The Care Management Nurse assesses, plans, facilitates, coordinates, monitors, and evaluates options and comprehensive services across the continuum of care, providing for safe, clinically appropriate discharge or transfer of all patients admitted to the Hospital.
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The primary purpose of this position is to assist the Credentialing Manager and Managed Care Director perform the duties required to credential all doctors for all medical and vision plans.
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R&C ensures risk is proactively identified, managed, mitigated, and governed in accordance with the enterprise risk management framework and in keeping with the Company’s risk appetite. Controls and processes include but are not limited to: incident response, asset inventory, vulnerability management, patch management, application security, logging and monitoring, findings governance and remediation, identity and access management, configuration management, and change management.
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Working knowledge of lnterQual IS-SI, Milliman and Robertson Managed Care Guidelines, Erickson Life Skills (Age Competencies}, Medicare Part A and Part B, Medi-Cal, NCQA, HEDIS and other criteria as identified by the Quality/Case Management Department.
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At least 3 years of progressively responsible work experience in Care Management (in an acute or managed care setting, and/or in training and education). The Care Management Health Educator II works under the guidance of a Manager or Director of the Department as required.
$102,183 - $132,838 a yearFull-timeExpandApply NowActive JobUpdated 1 month ago - UpvoteDownvoteShare Job
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This position is responsible for a team performing investment operations activities for the VRS fund by planning, organizing, and directing the middle and back-office functions for the internally managed public assets and alternative investments.
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Three years of experience where the primary function of the position was nursing in a hospital or health care agency, one of which must have been at a leadership level, and one year of which must have been in either a hospital, health care agency or managed care company in the area of utilization review, quality assurance, risk management or discharge planning.
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Responsible for the management and communication of denials/appeals received from third party payers, managed care companies, and/or government entities/auditors related to medical necessity and/or level of care.
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Minimum 2 years "telephonic" Case Management experience with a Managed Care Company preferred. The “Telephonic” Nurse Case Manager II is responsible for performing care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum.
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Collaborates with internal partners such as Middle and Front End revenue cycle leaders and Enterprise stakeholders; including, but not limited to, Managed Care. Information Services, Compliance, Risk Management, Case Management; Patient Relations; and clinical and operations leadership for the Hospital and the Medical Group to advance the organization’s mission and strategic plan.
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Provide account relationship support to the managed care account management teams by identifying and developing relationships with key decision makers/external experts within managed care organizations and other institutions that purchase or manage the use of Karuna products.
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A minimum of five years of executive level management and accounting experience in the health care field with increased levels of responsibility (including familiarity with 133 non-profit federal account procedures) required.
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Advanced degree in medical/biosciences (i.e., PharmD, MD, PhD.) AND minimum 3 to 5 years related experience (field liaison responsible for market access , worked for managed care organization, corporate or field HEOR, etc.
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Resolves grievances, appeals and external reviews for one of the following VNS Health Plans product lines – Managed Long Term Care (MLTC), Medicare Advantage (MA), or Select Health. Minimum three years progressive professional experience in health care, including a minimum of two years in a grievance and appeals or related area such as medical or utilization management required.
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care management managed jobs Title: management Company: Centene Corporation in Rogers, Arkansas
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