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.
Case ManagementUtilization ReviewPatient CareClinicalNegotiation
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.
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.
You will be responsible for using your assessment and communication skills to engage with patients in need of clinical support to determine and prioritize their needs.
Conduct timely telephonic clinical outreach to identified patients.
Collaborate with PCPs, NPs, and other members of the healthcare team to coordinate care for patients and actively help keep them stable at home.
Vytalize Health is building a market leader in value-based healthcare. They are a rapidly growing organization that embraces the power of AI and encourages innovative, responsible use of emerging technologies in their work.
Responsible for coordination of services for members, emphasizing education/self-management and quality care. \n- Assesses member needs, reviews service options, develops and implements care plans, and coordinates resources. \n- Manages a caseload of moderate-high risk members with complex medical/behavioral/psychosocial needs.
Capital Blue Cross is committed to improving the health and well-being of our members and the communities in which they live. They offer flexibility, prioritize health and well-being, and encourage employees to volunteer in their community.
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.
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.
Provides quality driven telephonic clinical assessments, health education, and utilization management services.
Provides assessments to individuals using telecommunications in accordance with computer-based algorithms, protocols, and guidelines.
Uses clinical knowledge to assess, disposition, make recommendations for care, provide education and health information.
Carenet Health values the expertise and dedication of their team members. They are committed to offering an appealing compensation package and creating an inclusive environment for all employees.
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.
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.
Coordinate and support the hospital’s Utilization Review and Case Management program.
Review patient charts and clinical documentation to verify medical necessity.
Monitor patient progress and coordinate care management strategies.
NeuroPsychiatric Hospitals is a national leader in behavioral healthcare, specializing in patients with acute psychiatric and complex medical needs. With hospitals in Indiana, Michigan, Texas, and Arizona, they’re expanding access to their unique model of care across the United States.
Reviews pre-admissions for correct classification and admission order.
Performs Utilization Review for each patient on their assigned daily census using established medical necessity guidelines.
Communicates with payers regarding authorization and medical necessity, utilizing excellent negotiating skills.
Oregon Health & Science University values a diverse and culturally competent workforce. They are an equal opportunity, affirmative action organization that does not discriminate against applicants.
Conduct assessments, establish care goals, and deliver telephonic coaching and education to support clients in managing chronic conditions.
Perform first‑level Utilization Review for inpatient and outpatient services based on plan guidelines.
Document all condition management activities, track client progress, and report outcomes, savings, and quality improvements.
HealthCheck360 focuses on reducing medical costs while increasing employee engagement and productivity. They accomplish this by providing onsite biometric screenings, engaging participants through technology and programming, educating the participant with risk-specific targeted communications, and supporting positive behavior change through Health Coaching and Condition Management programs.
Communicate and provide education to members and providers on insurance plan benefits and digital health solutions.
Employ active listening & motivational interviewing skills, and can handle difficult calls tactfully, professionally and document accordingly that can build patient trust and engagement.
Accurately track and document work on a variety of internal software tools and platforms.
Evry Health is on a mission to bring humanity to health insurance. They provide high-technology health plans that expand benefits, increase access and transparency, and feature a personalized, human approach. Evry Health is the major medical division of Globe Life (NYSE:GL), which has 16.8 million policies in force, and more than 3,000 corporate employees and 15,000 agents.
Reaches out to members telephonically to assist with referrals, authorizations, HHC, DME needs, medication refills, make provider appointments and follow ups, etc.
Creates cases, tasks, and completes assessments in Case Management module for all Hospital and SNF discharges
Works as a team with the Case Manager to engage and manage a panel of SNP members
Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve.
Deliver coordinated, patient-centered virtual Care Management by telephone or video that improves members' health outcomes.
Help members navigate complex medical conditions, treatment pathways, benefits, and the healthcare system in general.
Assist throughout acute healthcare episodes, such as hospitalizations and rehabilitation stays, providing coordinated Case Management to support the member and their family.
Included Health is a healthcare company that delivers integrated virtual care and navigation, aiming to raise the standard of healthcare for everyone. They break down barriers to provide high-quality care for every person, offering care guidance, advocacy, and access to personalized virtual and in-person care.
Work independently to make clinical decisions on routine patient care matters.
Provide patient-focused care and guidance on the phone or online.
Monitor your own performance with dashboard metrics and look for ways to improve.
Carenet Healthcare Services provides telehealth and virtual care clinical triage assessments, health education and other services to diverse populations of patients and health plan members. They are known to connect nurses and clinical staff with consumers as a trusted, behind-the-scenes partner for health plans and health systems.
Provide exceptional care, disease management and health education to patients
Support goal setting for individual patients asynchronously to help them better manage their chronic conditions
Create personalized action plans with guidelines to reduce or eliminate unwanted behaviors
Salvo is focused on chronic gut health and metabolic conditions from IBS to obesity, assigning patients a care team and providing app-based care seven days a week. Salvo is backed by leading health care investors from innovators; they offer a culture that drives constant innovation and is marked by relentless curiosity and a sense of empathy.
Play an active role in member registration and enrollment, including organizing community engagement and outbound outreach calls/texts.
Engage with a panel of assigned members to provide care navigation, appointment logistics, prescription drug support, lab support, referral coordination, care plan adherence support, and resource sharing.
Serve as the primary relationship holder for members with behavioral health needs; provide consistent outreach, follow-up, and re-engagement support, including after ED/inpatient discharge when applicable.
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. They combine local, community-based teams with virtual care and modern technology to deliver coordinated, whole-person care where members live and receive support.