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Collaborate with other organizational departments responsible for functional aspects of the HIV Special Needs Plan, including, but not limited to Integrated Care Management, Behavioral Health, Managed Long-Term Care, Utilization Management, Quality Management, Credentialing, Regulatory Affairs, Compliance, Corporate Affairs, Provider Network Operations, Medicare Services, Information Systems, Finance, Claims, and Member Services and Eligibility.
$150,000 - $157,236 a yearFull-timeExpandApply NowActive JobUpdated 3 months ago - UpvoteDownvoteShare Job
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Coordinate and track appropriate problem resolution activities with plan personnel in other departments (i.e. Enrollment and Membership Services, DST BPO and Utilization Management) In addition, this individual will work closely with multiple internal departments including Provider Network Operations, Medical Management, Enrollment and Membership services and BPO Products.
Full-timeExpandApply NowActive JobUpdated 24 days ago - UpvoteDownvoteShare Job
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Requires a demonstrated progressive understanding of managed care business processes, data, systems, and applications for claims payment, enrollment, benefit design, product pricing, network and provider contracting, and utilization management.
$93,000 - $127,050 a yearFull-timeExpandApply NowActive JobUpdated Yesterday - UpvoteDownvoteShare Job
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Minimum of 5 years medical advisory experience in occupational health, worker compensation, disability, health case management, or utilization review. · Ensure quality standards for case management are met; implement Reed Group’s continuous quality improvement process whenever efficiencies or quality standards are not met.
Full-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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RN in the Bay Area looking for a managment level position with Utilization Management experience ? Accountable for utilization management metrics and reporting to the QI Committee.
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Work with internal departments including Sales, Legal, Provider Network Management, Provider File Operations, Customer Service, and Utilization Management to gather information needed to resolve high dollar claim issues.
$52,000 - $92,000 a yearFull-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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Requires a progressive understanding of managed care business processes, data, systems, and applications for claims payment, enrollment, benefit design, product pricing, network and provider contracting, and utilization management.
ExpandApply NowActive JobUpdated 5 days ago - UpvoteDownvoteShare Job
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Experience with multiple Health Plan Operational departments (i.e., configuration, medical management, provider operations, customer service, utilization management, regulatory, etc.
ExpandApply NowActive JobUpdated 11 days ago - UpvoteDownvoteShare Job
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Requires minimum of two (2) years experience as a Pharmacy Utilization Management Specialist. This position is responsible for receiving verbal and written requests for prior authorization from pharmacists, physicians and/or patients and is responsible for supporting and assisting in the coordination of Pharmacy Services activities including claim utilization analysis, prescription plan design, ad-hoc reporting, correspondence and special projects.
ExpandApply NowActive JobUpdated 1 month ago - UpvoteDownvoteShare Job
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Directly interact with members of physician office staff, pharmacies and internal stake holders for eligibility, coverage determination claims issues. Prefers a Bachelor's degree from an accredited college or university in Health Care Management, Business or Pharmaceutical Administration.
ExpandApply NowActive JobUpdated 1 month ago - UpvoteDownvoteShare Job
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Job Description: This position is responsible for receiving verbal and written requests for prior authorization from pharmacists, physicians and/or patients and is responsible for supporting and assisting in the coordination of Pharmacy Services activities including claim utilization analysis, prescription plan design, ad-hoc reporting, correspondence and special projects.
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The primary responsibilities include but are not limited to documenting all customer contacts into the tracking system, process complaints, conduct outreach efforts, assist in PCP selection, conduct new member orientations, claims review inquiries, handle provider and utilization management inquiries, etc.
$25 - $30 an hourExpandApply NowActive JobUpdated 3 months ago - UpvoteDownvoteShare Job
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Utilization Management experience Preferred. Creates case files for services that require authorization and maintains accurate data in all applicable systems to ensure prompt decision-making and accurate claims adjudication.
ExpandApply NowActive JobUpdated 20 days ago - UpvoteDownvoteShare Job
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Care Management: Reviews all cases meeting criteria to determine if the member qualifies for TPTN’s internal Care Management program. Will facilitate all Care Management related communications being sent to the member.
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Delivers strong customer service and problem solving while providing triage and management of calls with accuracy of data collection and ensuring established call performance targets are consistently achieved.
ExpandApply NowActive JobUpdated 14 days ago
claims utilization management jobs in Newark, NJ
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