Perform initial and ongoing reviews pertaining to primary role (PA, ICM, DCM, PACM), appropriately applying clinical criteria (InterQual, policies, National and Local Coverage Determinations) for approval and sending to Medical Directors if review is necessary for determining an adverse determination Collaborate with Medical Directors, clinical peers and Health Plan partn

Engage members either face to face or over the phone to assist with closing gaps in care, linking to necessary services and providing education about their health Review available member service records and relevant documentation (e.g., utilization history, functional level, stratification information, current plan of care) Conduct member health assessment that includes p

Provide office and community based resource coordination and member education to help improve member wellness and quality of life Provide Housing Supports and Services as defined in state contract to eligible members experiencing housing insecurity Collaborate with internal teams and community organizations to support members through housing related needs Assist members i

Promote Excelsior's product portfolio to benefits brokers and help them increase their enrollment and average case size with all product lines Ability to negotiate and close sales Conduct in depth market presentations for brokers and employers Create and drive strategies for top producing agencies and Brokers Collaborate with Sales Management regarding pipeline, persisten

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, at least restrictive level of care Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact

Reviews surgical and other professional claims for correct coding using clinical record Participation in Training regarding URAC, NCQA, Regulatory Compliance, Confidentiality, Conflict of Interest, HIPAA, and department specific training as applicable Participates in periodic clinical conferences / calls and in ongoing internal performance consistency reviews Composes, if

Accountable for customer (employer) loyalty and satisfaction, as measured by survey results and persistency Establish, cultivate, and manage the customer relationship at multiple levels, serving as a healthcare consultant and trusted business advisor to these customers Establish, cultivate, and manage relationships with consultants and brokers, recognizing the value they

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connect

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, at least restrictive level of care Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact

Maintenance and enhancement of existing EDI solution built on EDI Fabric in C# Troubleshoot and resolve EDI technical issues, including diagnosis and root cause analysis Troubleshoot claim workflow issues from EDI intake through EDI export Develop and maintain monitoring tools to ensure EDI connectivity meets service level agreements Analysis and design of systems and con

Manage administrative intake of members Work with hospitals, clinics, facilities and the clinical team to manage requests for services from members and/or providers Process incoming and outgoing referrals, and prior authorizations, including intake, notification and census roles Assist the clinical staff with setting up documents/triage cases for Clinical Coverage Review

Analyze and report on financials Assist in the development of program forecasts, budgets, and plans Research economic progressions to assist with the organization's financial planning Create annual budget templates Prepare spreadsheets to effectively show financial results and financial forecasts You'll be rewarded and recognized for your performance in an environment tha

improving the quality, cost, and experience of health care. Here, we focus on delivering the best patient care, rather than volume. Through innovation and superior care management, we support patients and your well being as a team member. Join a team at the forefront of value based care and discover the meaning behind. The Nursing Internship Program is full time, 40 hours

improving the quality, cost, and experience of health care. Here, we focus on delivering the best patient care, rather than volume. Through innovation and superior care management, we support patients and your well being as a team member. Join a team at the forefront of value based care and discover the meaning behind. The Nursing Internship Program is full time, 40 hours

Territory will include priority markets in the Central and West Regions with a focus on MN, IL, TX, AZ, CO, and CA Sales VP qualify top prospect utilizing EDGE sales methodology; identifying/creating compelling events that position UHC for success Individual will be an expert at consultative selling with a demonstrated track record of leveraging UHG capabilities to solve