Education and/or Experience. At least 5 years of experience working in a Managed Care or Healthcare environment. Advanced certification or education within the healthcare arena preferred (i.e., MA, clinic, nursing school). Proficient with Microsoft word processing software including Word/Excel. Knowledge of medical terminology and healthcare insurance industry operating procedures. Bilingual English / Spanish (read, write, speak) is a preferred. ...
Position Summary. The Network Manager is responsible for general management of the provider network as assigned by the Director of Network Management as well as for supporting the Network Management Department in meeting the overall network growth and development goals. Essential Duties and Responsibilities include the following. Responsible for working collaboratively with the Director of Network Management and Medical Management team to ensure ...
Essential Duties & Responsibilities include the following. Provides leadership in the ongoing development and implementation of business strategy that is responsive to customer needs and supports fulfillment of Heritage Provider Network and Regal Medical Group mission and values for the assigned region. Develops and implements policies, processes and procedures necessary to achieve strategic objectives. Establishes and maintains an effective orga...
Position Summary. The Patient Advocate is designated to provide members with individualized service, allowing members the opportunity to make better informed, effective choices for their care. The Patient Advocate uses a combination of customer service skills, health system expertise, and strategic planning to optimize each member's care with a patient-centered approach. The Patient Advocate will work with Medical Management, Finance, Network and...
Position Summary. The role of the Prior Auth Coordinator is to promptly, efficiently and accurately execute all aspects of the referral process. Facilitating the right care at the right time in the right setting. Process requests from Access Express that are pended or reprocess approved or denied authorizations and package properly for review and resolution. Check eligibility and benefits on all DME and home health authorizations prior to forward...
Position Summary. The Project Manager for Continuous Quality Monitoring Department (CQM), directly reports to Vice President of CQM. The role is responsible for leading regulatory audit projects. Set up internal monitoring projects to monitor the UM process, reporting and UM activities compliance. The role also needs to work with different departments to coordinate or lead projects that related to CQM to ensure the company Utilization Management ...
Position Summary. Under the direction of Social Services Manager, the Social Worker will be collaborating closely with the Medi-Cal SPD Case Management Team, the Medi-Cal SPD, Outpatient and Inpatient teams. The Social Worker is responsible for assisting in the successful implementation of the Medi-Cal SPD (Seniors and Persons with Disabilities) Medical Management Program and all other line of services for the outpatient and inpatient teams. This...
We are looking for HCC Risk Adjustment Auditors/Coders to join our team. Position Summary. The HCC Risk Adjustment/Auditor is responsible for maintaining and monitoring the Quality Assurance auditing plan for outpatient clinical data. This position works to improve the quality of coding documentation and data in the medical record and HCC database. The HCC Risk Adjustment/Auditor reports on the accuracy and consistency of the data in accordance w...
Position Summary. The Denial Nurse is responsible for being the “second line” resource for preparing and maintaining health plan criteria for the campus Medical Directors. This includes collaborating with each Health Plan to obtain updated/adequate criteria for each specialty to ensure that appropriate criteria are referenced upon furnishing a denial. This includes questions regarding procedures, training, and processes to assure compliance with ...
Position Summary. This position will directly support the Vice President of Operations, Central Region providing coordination of administrative functions and supporting projects for the Clinical Operations department. Compiles data, performs data entry and runs reports. This position provides general assistance and support, interfaces with the executive team, Medical Directors, Management and all employees and will assist with special projects. T...
Position Summary. The Case Manager SNF LVN is responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation for identified skilled or custodial level patients. The goal of the Inpatient SNF Case Manager is to effectively manage the patients' SNF stay to assure the right level of care is provided and that all the patients' medical, environmental and psychosocial needs are met, both during their stay, im...
Position Summary. The Social Worker plays a critical role within the interdisciplinary team, performing psychosocial assessments of RMG Lakeside members/ACO beneficiaries and interpreting psychosocial implications of medical issues to case managers and primary care physicians as needed. Must be able to work with Dual eligible population (Medicare/Medi-Cal) as well as Medi-Cal population. Performs psychosocial assessments, crisis interventions. sa...
