Processes acute and post-acute inpatient medical or behavioral health and select intensive outpatient higher level of care requests through review of the submitted request and applicable clinical records
Collaborates with UM department staff, including Clinical Support Specialists and Medical Directors to make a final determination, and with Care Management staff on discharge planning and transition of care activities.
Identifies and refers members with complex needs to the appropriate population health and/or care management program.
Provide utilization management services, transition of care, and support to members and health care providers.
Utilize clinical knowledge to interpret medical policy and provide consultation on UM requests.
Proactively assess and assist members through the continuum of care by utilizing services and resources efficiently.
Wellmark is a mutual insurance company owned by its policy holders across Iowa and South Dakota, and it has built its reputation on over 80 years of trust.
Responsible for application of appropriate medical necessity tools to maintain compliance and achieve cost effective and positive patient outcomes.
Acts as a resource to other team members including UR Tech and AA to support UR and revenue cycle process.
Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity.
Virtua Health strives to connect individuals to the care they need, building a healthier community in South Jersey. They are a Magnet-recognized health system with over 14,000 colleagues, including over 2,850 doctors, physician assistants, and nurse practitioners.
Assists with medical record documentation requests and leverages medical management system to initiate case and/or authorization to support clinical processes.
Conducts fax and telephonic outreach; and written communications to members and/or providers to communicate status of UM/CM processes.
Actively participates in supporting department compliance and performance through administrative activities such as report monitoring/distribution, and other tasks as assigned by leadership.
Capital Blue Cross promises to go the extra mile for their team and community. Employees consistently vote it one of the “Best Places to Work in PA”.
Authorizes and reviews utilization of mental health and substance abuse services.
Collects and analyzes utilization data and assists with discharge planning and care coordination.
Provides member assistance with mental health and substance abuse issues, and participates in quality improvement projects.
Magellan Health, Inc. is committed to making a difference in the healthcare industry and communities. They value professional growth and development, total health and wellness, rewards and recognition, as well as employee unity, offering a place where you can thrive.
Develop trusting long-term patient relationships and empower you to do the best work of your career. Conduct holistic assessments to identify conditions, functional status and member values. Support chronic disease management, using motivational interviewing techniques.
Devoted Medical was founded on the belief that if we treat each member like we would our loved ones, we can meaningfully improve healthcare experiences.
Lead the preparation and submission of comprehensive provider rosters to Managed Medicare, Medicaid, and commercial payers.
Audit internal provider data against database records to ensure 100% accuracy before submission.
Serve as the primary point of contact for health plans to resolve roster discrepancies, rejections, or paneling delays.
Privia Health is a technology-driven, national physician enablement company that collaborates with medical groups, health plans, and health systems. The Privia Platform consists of scalable operations and end-to-end, cloud-based technology that reduces unnecessary healthcare costs.
Ensuring providers are credentialed in a timely manner by monitoring the submission process.
Monitoring submission processes, updating protocols, and managing Virtual Assistants/BPO.
Communicating with payors and conducting regular reviews to validate internal credentialing data.
Grow Therapy aims to be the trusted partner for therapists growing their practice, and patients accessing high-quality care. They are a three-sided marketplace that empowers providers, augments insurance payors, and serves patients and have empowered more than ten thousand therapists.
Manage client crises using evidence-based interventions, providing risk assessment and safety planning.
Identify roadblocks to clinical care and connect clients to the ideal treatment using Lyra’s proprietary software.
Independently manage a caseload of complex, multi-need clients.
Lyra Health is the leading provider of mental health solutions for employers, supporting more than 20 million people globally. They have delivered 13 million sessions of mental health care and are known for their AI-powered platform and focus on improving access to high-quality mental healthcare.
Work remotely to enhance member management and navigate the healthcare system.
Promote wellness and assist members in achieving their healthcare goals.
Conduct telephonic outreach, data analysis, clinical review, and documentation.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence, improving patient health, and restoring provider fulfillment.
Manage a diverse portfolio of miscellaneous medical and telehealth accounts, handling risk selection, pricing, retention, growth, and profitability.
Analyze submissions, determine terms, and price business according to guidelines.
Collaborate closely with the hiring manager to shape the product and contribute to the growth of this new product.
Great American Insurance Group's member companies are subsidiaries of American Financial Group, providing specialty and property and casualty operations. With over 8,500 employees, they foster a "small company" culture where ideas are heard, combined with "big company" expertise.
Manages client denials and concerns through analytic review of clinical documentation.
Delivers final determination based on skillsets and partnerships with Humana parties.
Investigates and resolves member and practitioner issues via phone or face to face to support quality goals.
Humana Inc. is committed to putting health first for teammates, customers, and the company. Through Humana insurance services and CenterWell healthcare services, they strive to make it easier for millions to achieve their best health, delivering needed care and service.
Acts as key point of contact for the processing of enrollment applications for all providers. Works with System Credentialing and local medical staff contacts. Responsible for completing the ongoing review and attestation of all Munson Healthcare provider enrollment records.
Munson Healthcare is northern Michigan’s largest healthcare system, with eight award-winning community hospitals serving over half a million residents.
Lead and supervise credentialing support staff, ensuring quality, accuracy, and timely processing of credentialing and enrollment tasks.
Oversee provider credentialing, licensure, and internal enrollment with Medicare, Medicaid, Managed Care, and Commercial Plans.
Maintain provider rosters, monitor license and certification renewals, and ensure compliance with regulatory and internal standards.
At Better Life Partners, we provide what it takes to heal from addiction. Wherever. Whenever. By combining virtual and in-person counseling, community support, and medication access.
Facilitate all aspects of required medical licensure for clinical personnel.
Drive the licensing process in a proactive, organized and streamlined manner.
Collaborate with credentialing, onboarding, and clinical teams.
Talkiatry is a national mental health practice co-founded by a patient and a triple-board-certified psychiatrist. They provide patients with the care they need and allow psychiatrists to focus on medicine with innovative technology and a human-centered philosophy.
Analyze claims data and develop cost-of-care projections for existing customer renewals and new business opportunities.
Responsible for cost pricing, including evaluating data, building underwriting, and evaluating profitability.
Manage team of pricing and reporting analysts.
Magellan Health, Inc. is committed to making a difference in the health care industry and in the communities where they work and live. They value professional growth and development, total health and wellness, rewards and recognition as well as employee unity.
Process transactions on insurance accounts and interact with insurance companies.
Communicate with staff and third-party customers to ensure accurate processing.
Prioritize accounts to maximize aged AR resolution, and research documentation.
Oregon Health & Science University values a diverse and culturally competent workforce. They are proud of their commitment to being an equal opportunity, affirmative action organization that does not discriminate against applicants on the basis of any protected class status, including disability status and protected veteran status.