Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.
Provide medical leadership of all for utilization management, cost containment, and medical quality improvement activities.
Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making.
Centene is committed to helping people live healthier lives. They provide access to high-quality healthcare, innovative programs and a wide range of health solutions that help families and individuals get well, stay well and be well. Centene values diversity and is an equal opportunity employer.
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.
Review and refine AI-generated clinical summaries and indicators related to medical necessity.
Collaborate with Product and Data Science teams to define and validate clinical logic.
Translate clinical knowledge into prompts and guidelines for large language models.
SmarterDx builds clinical AI that is transforming how hospitals translate care into payment. Founded by physicians in 2020, their platform connects clinical context with revenue intelligence, helping health systems recover millions in missed revenue, improve quality scores, and appeal every denial.
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.
Capital Blue Cross promises to go the extra mile for our team and our community. Our employees consistently vote us one of the “Best Places to Work in PA, and we foster a flexible environment where your health and wellbeing are prioritized.