Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, lease 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 Com

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, 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 Com

Support network pricing strategies and tactics, in collaboration with local network field leaders and network managers Analyze financial impact of provider contracts (e.g., facility; physician; ancillary) Analyze payment appendices to provide options for various contracting approaches and methodologies Communicate results of financial impact and analysis to appropriate st

Test Data Provision & Masking Operation Test data need & masking analysis ( Data structure, SQL queries) Working with Informatica tool to configure & invoke Data Copy and Masking jobs and maintain Gold Copy Maintenance of TDM Portal using UNIX scripting, Java Spring boot and Angular You'll be rewarded and recognized for your performance in an environment that will challen

Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medicati

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

Answer incoming phone calls from customers and identify the type of assistance the customer needs (i.e., benefit and eligibility, billing and payments, authorizations for treatment and explanation of benefits / EOBs) Ask appropriate questions and listen actively to identify specific questions or issues while documenting required information in computer systems Own problem

Make determinations of medical necessity/clinical appropriateness of treatment Assist in the development and implementation of clinical policy, guidelines and applications Regularly contact providers whose treatment determinations indicate a trend that varies with their peers and community Be knowledgeable on and apply all necessary regulatory requirements for assigned re

Mainly handling inbound calling, NO knocking on doors Answer incoming phone calls from prospective members and identify the type of assistance and information the customer needs with the goal to convert the caller to a qualified lead and ultimately sale Ask appropriate questions and listen actively to identify specific questions or issues while documenting required inform

Assist with care management for high medical risks / needs members with comorbid behavioral health needs As a Care Coordinator Assess members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic (SDoH) needs Develop and implement individualized, person centered

Answer incoming phone calls from prospective members, identify the type of assistance and information the customer needs with the goal to convert caller to a qualified lead and sale Follow up with members on questions or to review current or new products and services Navigate multiple computer systems to document member information while maintaining active listening and e

Engage members either face to face or over the phone to have a discussion about their health Review available member service records and relevant documentation (e.g., utilization history, functional level, stratification information, current plan of care) Conduct comprehensive member assessment that includes bio psychosocial, functional, and behavioral health needs Utiliz

Serves as primary care manager for members with primary high behavioral needs members Engage members through a variety of modalities (telephonically) to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, socioeconomic and SDOH needs Develops and implements individualized, person centered care plans inclusive of go

Answer incoming phone calls from prospective members, identify the type of assistance and information the customer needs with the goal to convert caller to a qualified lead and sale Follow up with members on questions or to review current or new products and services Navigate multiple computer systems to document member information while maintaining active listening and e

Evaluates new and on going claims to determine liability, giving consideration to contract provisions, disability management duration contract guidelines, medical evidence and vocational evidence. Investigates questionable claims. Determines need for additional medical information. Performs periodic follow ups to verify continued existence of a disabling condition. Respon