18 jobs found in getzville

Position Purpose: The Utilization Review Nurse II leads the daily activities of the Utilization Management RN I positions. Participates with the manager in the selection process for open UM RN positions. Conducts routine audits of the UM RN I job duties and oversees workload balancing. Provides first level clinical review for outpatient and ancillary services requiring authorization. Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. Answers Utilization Management directed telephone calls, managing them in a professional and competent manner. Processes all prior authorizations to completion utilizing appropriate review criteria. Identifies and refers all potential quality issues to the CQ& Department, and suspected fraud and abuse cases to Program Integrity. Serves as liaison between the TRICARE beneficiary and the Network Provider. Functions in a lead UM RN role and performs...

Position Purpose: Develop and drive security architecture, and design patterns to support IT and business solutions. The Architect is a thought leader on cyber security throughout the organization and especially within IT. Guide the organization in establishing policies, standards, and procedures which foster security built-in. Responsible for overall systems design and architecture, including new solutions and patterns Evaluate technical designs for vulnerabilities and risk based on Security Policies, Standards and best practices. Experience planning, researching, architecting and designing enterprise security solutions. Strong analytical and problem-solving skills to enable effective security incident and problem resolution. Extensive technical breadth, with depth in one or more technical and security domains. Ability to work well under minimal supervision and drive security initiatives linked to strategic milestones. Familiar with IT architectural and cybersecurity...

Position Purpose: The Utilization Review Nurse I provides first level clinical review for all outpatient and ancillary services requiring authorization. Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. Answers Utilization Management directed telephone calls; managing them in a professional and competent manner. Processes all prior authorizations to completion utilizing appropriate review criteria. Identifies and refers all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Program Integrity. Acts as liaison between the TRICARE beneficiary and the Network Provider. Provides first level RN review for all outpatient and ancillary prior authorization requests for medical appropriateness and medical necessity using appropriate criteria, referring those requests that fail review to the medical director for second level review and...

Position Purpose: Accountable for aligning human resources strategy with business strategy. Drives the HR agenda, partnering closely with Centers of Expertise (COEs), HR Operations and business unit leaders to effectively and efficiently deliver HR processes and initiatives for a business unit. Responsible for coaching the front line people managers and partner with them to resolve employee related matters Develop and analyze HR data to guide business leaders in planning and execution of people strategies Ensure efficiency and data integrity in completion of Workday business processes and reporting Investigate and resolve employee relations matters; respond to third parties when applicable Partner with HRBP leaders on local HR communication and implementation of HR initiatives/services Collaborate with COEs and HR Operations to ensure efficient and effective hiring, onboarding, terminations, etc. Partner with Absence Management; engage in interactive process and reasonable...