The D-SNP (Dual-Eligible Special Needs Plan) Nurse Navigator is responsible for the navigation and advocacy of members who are dually eligible for both Medicare and Medicaid. These members often have multiple or complex medical and/or behavioral health, socioeconomic, and functional needs that require comprehensive care coordination services. These services may include navigation beyond the specific case or situation, providing the member with a ...
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...
This is position is for the 8:00am - 5:00pm open or 11:00am - 8:00pm shift. The Customer Service Representative is responsible for answering phone calls in prompt and courteous manner to achieve contractual obligations. Responsible for answering Member's and Provider's questions with a quick and accurate response. They are also responsible for timely completion of all correspondence, faxes, emails, voicemail and reporting functions associated wit...
Under the direct supervision of the Manager of Credentialing, responsible for credentialing of providers and associated activities in support of the credentialing process in accordance with established Health Plan credentialing policies following NCQA, Medicare, the state of West Virginia, West Virginia Medicaid, and the state of Ohio policies and procedures. Required: . High school diploma or equivalent. At least two years related healthcare ex...
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...
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...
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 direction of the Manager of Claims, the reviewer performs initial review of claims, including HCFA 1500 and UB 04 claims. Reviewer must meet or exceed production and quality standards and follow documented policies and procedures. Required. High school diploma or equivalent. Ability to follow written directions and work independently. Familiarity with medical terminology, CPT and ICD-10 coding is required. Computer and typing experience...
Under the direction of the Manager of Claims, the reviewer performs initial review of claims, including HCFA 1500 and UB 04 claims. Reviewer must meet or exceed production and quality standards and follow documented policies and procedures. Required. High dipolma or equivalent. Ability to follow written directions and work independently. Familiarity with medical terminology, CPT and ICD-10 coding is required. Computer and typing experience is req...
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. Proficiency in Microsoft Excel, Microsoft Word and internet search engines. Strong verbal, written, analytical and interpersonal skills. Ability to work effectively independently. Strong organ...
Under the direct supervision of the Manager of Credentialing, responsible for credentialing of providers and associated activities in support of the credentialing process in accordance with established Health Plan credentialing policies following NCQA, Medicare, the state of West Virginia, West Virginia Medicaid, and the state of Ohio policies and procedures. Required: . High school diploma or equivalent. At least two years related healthcare ex...
