47 jobs found in carolina

Position Purpose: Under the direction of the Director of Care Management, the Supervisor of Care Management is responsible for implementing the Care Management programs in multiple environments including Prior Authorization, Concurrent Review and Care Management. Manages the daily operational processes to assure the continuum of care that addresses the ongoing needs of the members served by the care management process. A patient advocacy approach with a seamless integration of services is required and must be balanced within the member's benefit structure. Emphasis will be placed on continuity of care, assisting members in obtaining access to care, and member education. Directs personnel supervision of associates to include hiring, training and performance evaluations. Assures appropriate triage of members at risk. Supervises the assessment of members' situations and functioning, assuring identification of individual needs. Assures assessment information is used to develop a...

Position Purpose: Conducts home/facility visits to perform a comprehensive health re-assessment regarding clinical, behavioral and home safety requirements on existing members in the community as required by the state for the Managed Long Term Care program. Candidate Education: Required An Associate's Degree in Nursing or related field Essential Functions: * Conducts home/facility visit(s) for comprehensive health re-assessments regarding clinical, behavioral and home safety requirements on existing members. * Identifies applicant's health needs and completes medical assessment of applicant. * Tracks assessment schedule and updates assessments in a timely manner. * Initiates direct communication with health care providers involved in care of the applicant to obtain complete and accurate information as needed. * Collects information concerning ongoing eligibility. * Coordinates with Care Management team and provides updates regarding member health status. * Inputs visit and...

Position Purpose: This position performs advanced and complicated case review and first level determination approvals for inpatient, outpatient and ancillary services requests. Includes medical appropriateness and medical necessity determination requiring considerable clinical judgment, independent analysis, critical-thinking skills and detailed knowledge of departmental procedures and clinical guidelines. Identifies and refers all potential quality and suspected fraud and abuse cases to the appropriate department/associate. Acts as liaison between the beneficiary and the network provider and HN to utilize appropriate and cost effective medical resources. Acts as a resource for training, policy and regulatory/accreditation interpretation. Demonstrates regular, reliable and predictable attendance. Conducts advanced and complicated clinical review for inpatient, outpatient and ancillary services requests for medical appropriateness and medical necessity using considerable...

Position Purpose: Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests. Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care Educate providers on utilization and medical management processes Provide clinical knowledge and act as a clinical resource to non-clinical team staff Enter and maintain pertinent clinical information in various medical...

Position Purpose: Analyze and resolve verbal and written claims and authorization appeals from providers and pursue resolution of formal grievances from members. Gather, analyze and report verbal and written member and provider complaints, grievances and appeals Prepare response letters for member and provider complaints, grievances and appeals Maintain files on individual appeals and grievances May coordinate the Grievance and Appeals Committee Support the pay-for-performance programs, including data entry, tracking, organizing, and researching information Assist with HEDIS production functions including data entry, calls to provider's offices, and claims research. Manage large volumes of documents including copying, faxing and scanning incoming mail Education/Experience: High school diploma or equivalent. Associate's degree preferred. 2+ years grievance or appeals, claims or related managed care experience. Strong oral, written, and problem solving skills. Centene...

Remote, Telephonic position, Must be licensed in South Carolina Position Purpose: Perform duties to authorize and review utilization of mental health and substance abuse services provided in inpatient, outpatient and intermediate care settings, provide and/or review intakes and initial evaluations, brief focused treatment interventions, monitor quality of care, collect and analyze utilization and cost of care data, assist with discharge planning, arrange transportation; provide member assistance and participate in special utilization projects. Authorize, direct and monitor care for mental health and substance abuse problems according to clinical information given by providers and internal criteria for medical necessity and appropriateness of care. Ensure compliance with all performance measures in regards to appeals, denials, higher level of care admission certification and concurrent review timeliness, Outpatient Treatment Report review timeliness, readmissions, and others...