Responsible for the coordination of services for members meeting established criteria, emphasizing education/self-management and promoting quality care and cost-effective outcomes.\n- Uses a collaborative process to assess Member needs, review options for services and resources, develop and implement a plan of care, coordinate resources, monitor progress, and evaluate Member status.\n- Addresses medical, psychosocial, clinical needs, and behavioral health needs including members with mental health and substance use disorder needs, providing counseling and referrals to community/local/state programs.
Communication SkillsCritical ThinkingCustomer Service
Contact patient and complete a thorough assessment, including physical, psychosocial, emotional, spiritual, environmental, and financial needs.
Develop treatment plan for standard and catastrophic cases in collaboration with the patient, caregivers or family, community resources and multi-disciplinary healthcare providers that include obtainable short- and long-term goals.
Advocate for the patient by facilitating the delivery of quality patient care, and by assisting in reducing overall costs; provide patient/family with emotional support and guidance.
Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. They serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes and have a mission to empower people to lead healthier lives.
Processes acute and post-acute inpatient medical and select intensive outpatient higher level of care requests through clinical review.
Interprets and applies InterQual criteria, CMS-issued guidelines, Capital Blue Cross Medical Policies to requests.
Collaborates with UM department staff and Medical Directors to make a final determination, and with Care Management staff on discharge planning.
Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association. At Capital, employees work alongside a caring team of supportive colleagues and are encouraged to volunteer in their community.
Collaborate with hospitals, rehabs, and SNFs to manage patient’s inpatient stay and desired discharge plan
Communicate effectively with internal and external stakeholders in order to promote Bluestone’s mission and maintain patient health
Help reduce unnecessary visits to the emergency departments as to acute settings with the goal of reducing utilization and unnecessary costs
Bluestone delivers great outcomes by bringing exceptional care to patients living with complex, chronic conditions and disabilities. Bluestone has been named to the Star Tribune's Top Workplace list for the 13th year in a row!
Collaborates with members, family, and healthcare providers to coordinate services and address barriers.
Guides members to achieve optimal health by providing tools and information to understand their healthcare options.
Identifies and assesses members’ medical, behavioral, social, emotional, and financial needs.
Capital Blue Cross promises to go the extra mile for their team and community. They are one of the “Best Places to Work in PA”, with a caring and supportive culture that values professional and personal growth through training and continuing education.
Provide case management to members including medical, social, psychological, physical, and spiritual needs.
Develop, implement, and monitor the care plan in conjunction with the PCP, caregivers, and other team members.
Help meet the member's needs.
Elderplan and HomeFirst are Medicare and Medicaid managed care health plans that are expanding services in response to patients' needs. At MJHS, they are a supportive community committed to excellence, respect, and providing high-quality, personalized health care services.
Responsible for the Care Coordination staff for case reviews and UR appeals.
Coordinates worklists and completion of cases on audit review, retro authorization and appeals.
Northside Hospital is an award-winning and state-of-the-art healthcare provider that is constantly growing. They are expanding the quality and reach of their care to patients and communities, creating more opportunity for healthcare professionals in Atlanta and beyond.
The Case Manager is a key member of the interdisciplinary care team (ICT).
They use a collaborative process of assessment, planning, coordinating, and monitoring to meet members' health and social needs.
They act as a liaison between Members, their Responsible Parties, the Advance Plan Provider/PCP, and key stakeholders.
Curana Health aims to radically improve the health, happiness, and dignity of older adults. They are a national leader in value-based care, serving 200,000+ seniors in 1,500+ communities across 32 states with a team of more than 1,000 clinicians alongside care coordinators, analysts, operators, and professionals from all backgrounds.
Enhance the quality of member management and maximize satisfaction.
Assist in navigating the health care system as a collaborative health partner.
Promote wellness, problem-solve, and assist members in realization of their personal health-care related goals.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers.
Coordinate and implement medical case management to facilitate case closure.
Assess appropriate utilization of medical treatment and services.
Review medical records and assess data to ensure appropriate case management process.
Berkley Medical Management Solutions (BMMS) provides managed-care service for W.R. Berkley Corporation, focusing on injured worker’s return to work. BMMS was started in 2014 and combines clinical practices, return-to-work strategies, and software for workers’ compensation cases.
Coordinates and oversees all direct and indirect patient services provided by clinical organization personnel.
Provides guidance and counseling to coordinators and Clinical Supervisors to assist them in continually improving all aspects of home health care services.
Assists the Executive Director in the preparation and administration of the organization's budget.
Mission Healthcare, located in seven states, is the largest home health and hospice company in the western United States. They provide services that meet the needs of patients and families across the healthcare continuum and believe their people deserve care delivered with Compassion, Accountability, Respect, Excellence and Service.
Provide clinical oversight and guidance to CHWs and BHCMs, including escalation support for complex and high-risk patients
Lead clinical case reviews, identifying gaps in care and ensuring care plans are clinically appropriate and aligned with health plan requirements
Support care coordination across medical, behavioral health, and social needs, including collaboration with external providers and hospitals
Zócalo Health is a tech-enabled, community-oriented primary care organization serving people who have historically been underserved by the one-size-fits-all healthcare system. Founded in 2021, Zócalo Health is backed by leading healthcare and mission-aligned investors and is scaling rapidly across states and populations.
Assess referred concurrent denials and determine next steps for resolution.
Review medical record documentation to support denial management strategies.
Advocate for patients to ensure coverage and reimbursement.
They are currently looking for a Utilization Management Coordinator. By enhancing operational efficiencies and implementing educational initiatives, this role significantly impacts the financial and quality outcomes of healthcare delivery.
Conduct targeted patient outreach to close care gaps and ensure timely care transitions.
Deliver high-touch engagement for high-risk patients to prevent readmissions through follow-up.
Collaborate with Practices to support interventions such as Transitional Care Management.
Aledade empowers independent primary care practices, helping them deliver better care and thrive in value-based care. Founded in 2014, they are the largest network of independent primary care in the country with a collaborative, inclusive, and remote-first culture.
Evaluates certification requests by reviewing the group specific requirements.
Triage the call to determine if a Utilization Review Nurse is needed to complete the call.
Cottingham & Butler sells a promise to help their clients through life’s toughest moments. Their culture is guided by the theme of “better every day” constantly pushing themselves to be better than yesterday.
Monitor high-risk pediatric patients, ensuring appropriate follow-up and clinical management, and adjusting care plans as needed.
Conduct biopsychosocial assessments to address behavioral, social, emotional, and systemic needs of the patient and family.
Create and evaluate the effectiveness of the patient/family’s care plan and modify based on families evolving needs and goal progression.
Imagine Pediatrics is a tech-enabled, pediatrician-led medical group that reimagines care for children with special health care needs. They deliver 24/7 virtual-first and in-home medical, behavioral, and social care, working alongside families, providers, and health plans.
Complete timely review of healthcare services using appropriate medical criteria to support determinations.
Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards, and Guidehealth policies.
Communicate precertification and concurrent review decisions—verbally and in writing—to required parties within defined timeframes.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. They aim to make great healthcare affordable, improve patient health, and restore fulfillment in practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages Healthguides™ and a Managed Service Organization to build stronger connections with patients and providers.
Assess, plan, coordinate, and monitor patient care.
Develop, implement, and monitor individualized care plans.
Coordinate care across providers, facilities, and community resources.
Limitlessli specializes in recruiting, hiring, and managing high-caliber remote staff for dynamic and growing healthcare facilities. They connect clients with highly qualified professionals, offering tailored services to meet unique business needs, leveraging an extensive global network.
Review clinical information to meet Medical Necessity Criteria.
Requires knowledge of managed care contracting and clinical review requirements.
Ensures accurate information is entered into claims system.
Sentara Health is a not-for-profit integrated healthcare provider based in Virginia and Northeastern North Carolina that has been in business for over 131 years. It has close to a 30,000-member workforce, and diversity, inclusion, and belonging is a guiding principle of the organization.
Managing the care of patient panel by leveraging experience and knowledge.
Establishing relationships with patients and families to provide support.
Serving as an advocate and community liaison for patients.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach. We are committed to improving patient outcomes and quality of life by delaying disease progression and shifting care to the home.