Position Purpose: Perform collaborative duties for the development and implementation of all Coordinated Care programs (OB/NICU, Asthma, Diabetes, ER, General/Catastrophic); Provide support and supervision to ensure quality and continuity of services delivered to Members, Providers and staff. Develop and oversee aspects of coordinated care program activities Develop and implement management software and reporting mechanisms for specific outcome measurement and data reporting Identify referrals for coordinated care programs. Develop plan specific literature and educational components for member and provider distribution. Oversee contract negotiation and execution components for Prenatal Coordinated Care (PNCC) entities Collaborate with various departments to extract data for identification of program members and to report program outcomes Identify processes and work flow improvements to foster efficient and effective case management efforts Monitor distribution of members...
Jan 21, 2021
Position Purpose: Perform collaborative duties for the development and implementation of all Coordinated Care programs (OB/NICU, Asthma, Diabetes, ER, General/Catastrophic); Provide support and supervision to ensure quality and continuity of services delivered to Members, Providers and staff. Develop and oversee aspects of coordinated care program activities Develop and implement management software and reporting mechanisms for specific outcome measurement and data reporting Identify referrals for coordinated care programs. Develop plan specific literature and educational components for member and provider distribution. Oversee contract negotiation and execution components for Prenatal Coordinated Care (PNCC) entities Collaborate with various departments to extract data for identification of program members and to report program outcomes Identify processes and work flow improvements to foster efficient and effective case management efforts Monitor distribution of members...
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...
Jan 20, 2021
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...
Position Purpose: Serve as a liaison for external groups and providers regarding clinical information from the Operations and Medical Management teams Implement and manage procedures for tracking, identifying and problem-solving operational issues Interpret and present program results and develop data-driven analysis and metrics used to measure effectiveness and ROI of all current and new products Act as the clinical representative in various meetings Collaborate with staff to identify internal and external opportunities and initiate process changes to increase quality and improve staff, provider and member satisfaction Serve as a resource and liaison on utilization, quality improvement, and case management activities Partner with various staff, along with internal and external departments on provider education and outreach Partner with regional leadership for providers requiring a clinical interpretation of results related to health plan reporting, data, and quality...
Jan 20, 2021
Position Purpose: Serve as a liaison for external groups and providers regarding clinical information from the Operations and Medical Management teams Implement and manage procedures for tracking, identifying and problem-solving operational issues Interpret and present program results and develop data-driven analysis and metrics used to measure effectiveness and ROI of all current and new products Act as the clinical representative in various meetings Collaborate with staff to identify internal and external opportunities and initiate process changes to increase quality and improve staff, provider and member satisfaction Serve as a resource and liaison on utilization, quality improvement, and case management activities Partner with various staff, along with internal and external departments on provider education and outreach Partner with regional leadership for providers requiring a clinical interpretation of results related to health plan reporting, data, and quality...
