Coordinates and integrates through review, all services that require pre-authorization including all new technology and experimental/investigational services using the clinical review algorithm and/or responsible to identify members that may require coordinated care management or disease management services, or transition of care services based on clinical risk scores, or information gathered from preauthorization review of submitted clinicals. ....
Responsible to conduct systematic admission, concurrent, and retrospective hospital reviews for severity of illness and length of stay, to manage an inpatient admission, and to implement discharge planning and make discharge survey alls as required with pertinent clinical information and mandatory data with intervention and follow-up as identified using clinical review algorithm and department standard of operations. and/or Coordinates through pe...
Position Summary. The MHT Director, Contract Compliance and Administration, is responsible for the overall delivery of the WV Medicaid/WVCHIP Mountain Health Trust managed care contract with the WV Bureau for Medical Services (BMS). The Director is responsible for meeting as needed with BMS, legislators, other government bodies, community partners and other stakeholders, as necessary. The Director must maintain a positive client relationship, pro...
Coordinates and integrates through review, all services that require pre-authorization including all new technology and experimental/investigational services using the clinical review algorithm and/or responsible to identify members that may require coordinated care management or disease management services, or transition of care services based on clinical risk scores, or information gathered from preauthorization review of submitted clinicals. R...
Coordinates and integrates through review, all services that require pre-authorization including all new technology and experimental/investigational services using the clinical review algorithm and/or responsible to identify members that may require coordinated care management or disease management services, or transition of care services based on clinical risk scores, or information gathered from preauthorization review of submitted clinicals. R...
The Medicare Enrollment Representative is responsible for timely processing of enrollment and disenrollment requests using CMS guidelines and policies. They are also responsible for timely completion of all correspondence and reporting functions associated with the Medicare Enrollment Unit and have knowledge of how the Enrollment functions affect other Plan Units and Departments. The Medicare Enrollment Representative provides Sales Support as ne...
The ESS is responsible for managing document queues to complete member reimbursement requests, provider pricing verification requests, network pricing appeals, and member balance bills. The ESS will also prepare pricing appeal response letters and other written correspondence sent via email or postal service including certified mail when needed. The ESS is responsible for timely completion of requests from the operations team. Required. High Scho...
Under the general direction of the Pharmacy Operations Manager, the Member Advocate is responsible for coordinating copay assistance for members and directing members on how to apply for low-income subsidy for Medicare Part D. Required. High School diploma or equivalent. National Pharmacy Technician Certification. One year experience in a retail, hospital, managed care, or other similar pharmacy setting. Minimum typing speed of 35 words per minut...
This position is NOT remote. As a Senior Software Engineer, you will play a key leadership role in architecting, building, and optimizing secure, scalable integration solutions across diverse systems. You will serve as both a technical expert and mentor, guiding a team of engineers and developers to deliver modern, robust software and data workflows. This role is ideal for an engineer who thrives in architect-level problem solving, enjoys technic...
The Case Management/Disease Management Nurse Navigator is responsible for assessing moderate to high risk patients for case management/disease management intervention and coordinating the delivery of cost-effective, quality-based health care services for health plan members by development and implementation of care plans that address individual needs of the member, their benefit plan, and community resources. Directs intervention with moderate to...
The Case Management/Disease Management Nurse Navigator is responsible for assessing moderate to high risk patients for case management/disease management intervention and coordinating the delivery of cost-effective, quality-based health care services for health plan members by development and implementation of care plans that address individual needs of the member, their benefit plan, and community resources. Directs intervention with moderate to...
The Case Management/Disease Management Nurse Navigator is responsible for assessing moderate to high risk patients for case management/disease management intervention and coordinating the delivery of cost-effective, quality-based health care services for health plan members by development and implementation of care plans that address individual needs of the member, their benefit plan, and community resources. Directs intervention with moderate to...
