Review and process appeals submitted by members and providers, ensuring timely and accurate resolution.
Evaluate cases, determine next steps, and manage multiple priorities while meeting strict turnaround times.
Review clinical and medical records, summarize findings for Medical Director review, and operate within turnaround times as short as 24–72 hours.
BlueCross BlueShield of Tennessee has been helping Tennesseans find their own unique paths to good health since 1945. At BCBST, they empower their employees to thrive both independently and collaboratively, creating a collective impact on the lives of their members.
Coordinate care and collaborate with multiple disciplinary team members to improve the quality of care and clinical outcomes.
Conduct thorough assessments to determine unmet needs and develop individualized care plans.
Promote quality cost-effective outcomes with the goal of improved care coordination.
Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services. They strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships.
Pulling, sorting, and analyzing data to determine member eligibility for the Population Health management Program.
Coordinating and providing care that is timely, effective, equitable, safe, and member-centric while following HMO processes.
Managing case assignments which includes outreach, documentation, monitoring for case progression, and case closure.
Guidehealth is a data-powered healthcare company dedicated to operational excellence. They aim to make healthcare affordable, improve patient health, and restore fulfillment in practicing medicine. Guidehealth is a growing and innovative organization and employees are expected to adapt to evolving business needs.
Function autonomously and in collaboration with healthcare teams to coordinate quality, cost-effective care for ESRD and CKD patients.
Coordinate care between patient, family, physician, provider, community, and Regional Operations Manager.
Minimize fragmentation of the healthcare delivery system.
DaVita Inc. is a comprehensive kidney care provider focused on transforming care to improve the quality of life for patients globally. As of March 31, 2022, DaVita served 200,800 patients at 2,809 outpatient dialysis centers in the U.S.
Evaluates member health metrics and professional resources to inform UM/CM initiatives and programs.
Refers members and providers to G.E.H.A resources and programs, as indicated, maximizing their health plan benefits.
Monitors and evaluates program effectiveness, tracks relevant metrics, and reports outcomes.
Government Employees Health Association (G.E.H.A) is a nonprofit member association providing health and dental benefits to millions of federal employees and retirees since 1937. G.E.H.A is headquartered in Lee's Summit, Missouri, offering hybrid and work-from-home options for many roles.
Coordinate referrals, specialty access, and follow-ups as a patient advocate and liaison.
Collect, trend, and analyze outcomes data to enhance program performance and identify best practices.
Educate patients and families on treatment and navigation, and support staff training and skill development.
Cardiac Study Center provides compassionate, innovative cardiology care to improve heart health. With over 50 years of experience in the Pacific Northwest, it is a mission-driven organization with a tight-knit, collaborative team.
Conduct telephonic case management including comprehensive patient assessments and developing collaborative treatment plans.
Monitor and evaluate intervention effectiveness, maintain detailed documentation, and perform utilization reviews.
Advocate for patients, negotiate cost management strategies, and maintain relationships with providers and caregivers.
Personify Health provides a personalized health platform integrating health plan administration, holistic wellbeing solutions, and care navigation. The company has a mission-driven culture that values diversity and inclusion, empowering a team dedicated to improving health outcomes.