Position Purpose: Perform various analysis and interpretation to link business needs and objectives for assigned function. Support business initiatives through data analysis, identification of implementation barriers and user acceptance testing of new systems. Identify and analyze user requirements, procedures, and problems to improve existing processes. Perform detailed analysis on assigned projects, recommend potential business solutions and assist with implementation. Identify ways to enhance performance management and operational reports related to new business implementation processes. De... view job details
Position Purpose:. Perform various analysis and interpretation to link business needs and objectives for assigned function. Support business initiatives through data analysis, identification of implementation barriers and user acceptance testing of various systems. Identify and analyze user requirements, procedures, and problems to improve existing processes. Perform detailed analysis on multiple projects, recommend potential business solutions and ensure successful implementations. Identify ways to enhance performance management and operational reports related to new business implementation p... view job details
Position Purpose:. Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care. Develop, assess and adjust, as necessary, the care plan and promote desired outcome. Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options. Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as ne... view job details
Position Purpose:. *Position supports the Foster Care population state-wide* Perform care management duties to assess, plan and coordinate all aspects of behavioral health, medical and supporting services across the continuum of care for select members to promote quality, cost effective care. Develop, assess and adjust, as necessary, the member's plan of care to promote improved health outcomes. Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options. Coordinate services... view job details
Position Purpose: Serve as a liaison between the plan, claims, providers and various departments to effectively identify and resolve claims issues. Audit check run and send claims to the claims department for corrections. Identify any system changes and work notify the Plan CIA Manager to ensure its implementation. Collaborate with the claims department to price pended claims correctly. Document, track and resolve all plan providers’ claims projects. Collaborate with various business units to resolve claims issues to ensure prompt and accurate claims adjudication. Identify authorization issues... view job details
Position Purpose: Serve as the claims payment expert for the Plan and as a liaison between the plan, claims, and various departments to effectively identify and resolve claims issues. Act as the subject matter expert for other Claims Liaisons. Analyze trends in claims processing issues and identify work process solutions. Lead meetings with various departments to assign claim project priorities and monitor days in step processes to ensure the projects stay on track. Assist in the writing work processes and continual auditing of the processes to ensure configuration, state mandates, benefits, e... view job details
Position Purpose: Work with Marketing & Community Relations Manager to develop and implement community outreach plan for the Health Plan. Participate as a member of the Marketing team in developing and implementing strategies to support the department and company. Contribute to the attainment of member growth goals. Maintain thorough knowledge of Healthcare programs and associated regulatory marketing guidelines. Identify and develop relationships with new community contacts and organizations to pursue outreach engagements. Develop and implement promotional plan for new outreach opportunities.... view job details
Position Purpose: Perform day to day duties and testing of contract implementation, including UAT to ensure that systems accurately reflect a contract’s negotiated terms. Perform audits of provider setup within the provider information system to ensure accurate contract implementation and subsequent claims processing. Review and price contract related pends to ensure claims payment accuracy. Ensure accurate contract implementation and subsequent claims processing through provider setup, UAT testing, etc. on basic Change Requests (CRs) (i.e.RHCs/FQHCs/fee schedule updates). Troubleshoot and pro... view job details
Position Purpose:. Respond to customer inquiries via telephone and written correspondence in a timely and appropriate manner. Respond to telephone or written correspondence inquiries from members and/or providers within established timeframes utilizing current reference materials and available resources. Provide assistance to members and/or providers regarding website registration and navigation. Document all activities for quality and metrics reporting through the Customer Relationship Management (CRM) application. Process written customer correspondence and provide the appropriate level of t... view job details
Position Purpose:. Resolve customer inquiries via telephone and written correspondence in a timely and appropriate manner. Reference current materials to answer escalated and complex inquiries from members and providers regarding claims, eligibility, covered benefits and authorization status matters. Provide assistance to members and/or providers regarding website registration and navigation. Educate members and/or providers on health plan initiatives Provide first call resolution working with appropriate internal/external resources, and ensure closure of all inquiries. Document all activities... view job details