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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.
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Position Overview Under the direction of the Medical Director for Partnership in Care (PIC), the Director of Care Management (PIC) provides clinical and administrative direction to Partnership in Care care management staff who are focused on providing high quality clinical support and health education to members with HIV and those at risk of HIV infection to ensure these members receive the best possible care and achieve optimal health and wellness.
$150,000 - $157,236 a yearFull-timeExpandApply NowActive JobUpdated 3 months ago - UpvoteDownvoteShare Job
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Familiarity with state Traffic Management Center (TMC), insurance, claims, and recovery processes. Provide support and utilization of LCAMS/VA Traffic and VDOT HMMS systems. Coordinate front office activities, including reception area management, mail distribution, and office services.
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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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Internal Operations and Technology : Support efforts to improve the efficiency of health plan operations (utilization management, claims payment, provider contracting) to reduce friction for members, providers, and associates.
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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.
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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.
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Knowledge of claims processing rules and coding experience with DRG, ICD10 and CPT4 (Required) 3 - 5+ years' claims processing experience, preferably working in an HMO, managed care or self-insured environment (Required.
$52,000 - $92,000 a yearFull-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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Minimum of three(3) years of experience as an associate medical director or medical director working with utilization management, peer review, network assessment and provider relations, and quality improvement, preferably in an HMO environment.
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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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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.
$20.98 - $26.23 an hourExpandApply NowActive JobUpdated Today - 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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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.
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Schedule marketing appointments for prospective enrollees Respond to all claim billing inquiries from providers and members All other duties and special projects as assigned by Associate Executive Director.
$25 - $30 an hourExpandApply NowActive JobUpdated Today
claims utilization management jobs in Bronx, NY
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