Works within Department of Labor and State guidelines Adherence to all confidentiality regulations and agreements Reviews and interprets Plan language appropriately Utilizes clinical guidelines and criteria appropriately Responsible for accurately documenting determinations Effectively and professionally communicates with both internal and external customers/providers, fo

Responsible for the oversight of training and maintenance of LHI's Network Providers to ensure performance of quality services that result in successful event fulfillment Responsible for servicing provider network and event specific decisions including event specific fee schedules and concessions Oversee the initial and continuing education training for providers pertaini

Provide oversight of functional supervisory staff for all operational teams that are part of the Provider Network Management (PNM) department Provide strategic and operational management of LHI Provider Network Operations Manage, mentor, and evaluate staff with a focus on provider and practitioner quality, provider pricing, compliance with network requirements, department

Provide preventative and primary care for members in assigned skilled nursing and assisted living facilities Provide comprehensive visits for United Healthcare members in a short stay/transitional care setting within assigned skilled nursing facilities Work with the facility's utilization review process In this role, you'll also explore and learn more about palliative car

Serve as key HCE resource for CMS' ACA risk adjustment and RADV processes, including responses to CMS inquiries and analysis of potential program changes Oversee risk score calculations for large commercial blocks of business Measure impact of various initiatives designed to control costs Design and run complex data programs as you perform quantitative analysis of actuari

Provide general claims support by reviewing, researching, investigating, processing, and adjusting claims. Conduct data entry and re work Analyze and identify trends and provide reports as necessary Consistently meet established productivity, schedule adherence, and quality standards Recognize claims by determining claim type HCFA, Hospital, Dental, and/or RX Identify mor

Provide general claims support by reviewing, researching, investigating, processing, and adjusting claims. Conduct data entry and re work Analyze and identify trends and provide reports as necessary Consistently meet established productivity, schedule adherence, and quality standards Recognize claims by determining claim type HCFA, Hospital, Dental, and/or RX Identify mor

Travel up to 100% Conduct in home assessments on health plan members Identify diagnoses to be used in care management and active medical management Formulate a list of current and past medical conditions using clinical knowledge, judgment, and current findings Communicate gaps in care to member's PCP Identify referral needs Identify urgent and emergent situations for prop

Provider Reimbursement Coordinators ensure network contracts and reimbursement policies and procedures are priced accurately on affiliated medical claims Recommend system changes on provider contracts that appear inaccurate in the NDB (UHC Provider Network Database) Be able to assist with UHC projects and other tasks related to provider repricing, as necessary and / or re

There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn't for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life's best work.(sm) In this role you'll be responsible for Assist a team of desktop support t

Conduct in home assessments on health plan members. Average visit is 45 60 minutes in length. Assessment is performed and completed electronically. HouseCalls Assessment includes Past medical history Review of systems Physical examination Medication review Depression screening Checking vitals, conducting a physical exam that includes monofilament test, urine dipstick, and

Combine two of the fastest growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that is improving the lives of millions. Here, innovation is not about another gadget; it is about making health care data available wherever and whenever people need it, safely and reliably.

The Social Worker's responsibilities include, but are not limited to Coordinates patient care processes to achieve desired quality outcomes and identifies/controls appropriate resource utilization Provide skilled interventions for patient/family support and/or resolution of patient/family crises; facilitating problem solving/decision making; advocacy and facilitation nece

Make outbound calls and receive inbound calls to assess members' current health status Identify gaps or barriers in treatment plans Provide patient education to assist with self management Make referrals to outside sources Provide a complete continuum of quality care through close communication with members via in person or on phone interaction Support members with condit

Oversee subcontractor management team, providing guidance on process and issues resolution Coordinate workflow and assist in labor invoice reconciliations, ensuring accurate and timely payment Ensure proper authorization and documentation is obtained before invoice processing Maintain organized filing and documentation control Vendor management Generate standard and ad ho