Contract Apr 25, 2025 Healthcare Outreach Resources: Provide resources who are trusted members of the communities served and/or have an unusually close understanding of the communities to facilitate access to health care services, improve the quality and cultural competency of those services, and improve member health outcomes. Outreach Coordinator Resources work to increase health literacy, reduce costs of services, and improve care.
Pay Rate $20.00 hrly.
Monday - Friday 8:00-5:00 pm
Work remotely and local Travel is required
Job Description
The overall approach for outreach workers is fluid and flexible based on identified quality and member outcome needs. The primary focus of the Outreach resources will be as follows:
Understand Member history and the physical, behavioral, and social factors that may be leading to less-than-ideal health outcomes or persistent gaps in care.
Utilize a whole health approach when interacting with Members and caregivers.
Working with Case Management to place outreach resources at point of care facilities to better facilitate member engagement and action.
Facilitate real time gap closure initiatives including but not limited to immunizations, telehealth visits, A1c tests, lead tests, and blood pressure readings.
Pivot priorities as necessary month to month based on HEDIS performance.
Engage member in care coordination and case management as necessary.
Educate member on health care benefits and services and monitor for over and/or underutilization.
Requirements:
Community Outreach Experience preferred
CHW Certification and/or CNA/HHA preferred
Vaccinated
Home Visits
Driver’s License required
High School Diploma/GED required
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Contract Apr 24, 2025 Healthcare Care Review Clinician I work with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing members’ ultimate care. This position is FULLY REMOTE. Schedule M-F 8am-6pm EST or CST.
Day to Day Responsibilities:
Review Prior auth/Inpatient/Skilled Nursing requests for medical necessity using State/Policy or MCG criteria.
KNOWLEDGE/SKILLS/ABILITIES
• Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
• Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
• Conducts prior authorization reviews to determine financial responsibility for members.
• Processes requests within required timelines.
• Refers appropriate prior authorization requests to Medical Directors.
• Requests additional information from members or providers in consistent and efficient manner.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote Care Model
• Adheres to UM policies and procedures.
Must Have Skills:
at least 1 year UM experience in a HP setting
LPN or RN
The ability to work remote in a high pace/high demand environment.
The ability to complete 15-20 authorization in a day
Previous experience using QNXT/UMK2/PEGA preferred
MCG Experience preferred.
Required Years of Experience:
1 Required
Licensure / Education:
RN or LPN
Contract Apr 22, 2025 Healthcare Outreach Resources: Provide resources who are trusted members of the communities served and/or have an unusually close understanding of the communities to facilitate access to health care services, improve the quality and cultural competency of those services, and improve member health outcomes. Outreach Coordinator Resources work to increase health literacy, reduce costs of services, and improve care.
Pay Rate $20.00 hrly.
Monday - Friday 8:00-5:00 pm
Work remotely and local Travel is required
Job Description
The overall approach for outreach workers is fluid and flexible based on identified quality and member outcome needs. The primary focus of the Outreach resources will be as follows:
Understand Member history and the physical, behavioral, and social factors that may be leading to less-than-ideal health outcomes or persistent gaps in care.
Utilize a whole health approach when interacting with Members and caregivers.
Working with Case Management to place outreach resources at point of care facilities to better facilitate member engagement and action.
Facilitate real time gap closure initiatives including but not limited to immunizations, telehealth visits, A1c tests, lead tests, and blood pressure readings.
Pivot priorities as necessary month to month based on HEDIS performance.
Engage member in care coordination and case management as necessary.
Educate member on health care benefits and services and monitor for over and/or underutilization.
Requirements:
Community Outreach Experience preferred
CHW Certification and/or CNA/HHA preferred
Vaccinated
Home Visits
Driver’s License required
High School Diploma/GED required
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Contract Apr 21, 2025 Healthcare OB-GYN RN Care Manager to develop, assess, and facilitate complex care management activities for primarily physical needs members to provide high quality, cost-effective healthcare outcomes including personalized care plans and education for members and their families. Fully remote but MUST LIVE IN INDIANA. The work schedule is Monday-Friday 8am-5pm.
Care Manager completes an average of 40-50 calls per day reaching out to members who are about to or have recently delivered a baby.
Conduct assessments to assess members’ well-being, newborn wellbeing and to assist with any needs
Assist members on scheduling postpartum appointments
Answer questions about postpartum and Newborn care.
Documenting in specific system
Develops ongoing care plans / service plans and collaborates with providers to identify providers, specialists, and/or community resources to address member's unmet needs
Identifies problems/barriers to care and provide appropriate care management intervention
Coordinates as appropriate between the member and/or family/caregivers and the care provider team to ensure members are receiving adequate and appropriate person-centered care or service
Provides ongoing follow up and monitoring of member status, change in condition, and progress towards care plan / service plan goals; collaborate with member, caregivers, and appropriate providers to revise or update care plan / service plan as necessary to meet the member's goals / unmet needs
Provides resource support to members and care managers for local resources for various services (e.g., employment, housing, participant direction, independent living, justice, foster care) based on service assessment and plans, as appropriate
Facilitate care management and collaborate with appropriate providers or specialists to ensure members have timely access to needed care or services
May perform telephonic, digital, home and/or other site outreach to assess member needs and collaborate with resources
Education/Experience:
Requires a Degree from an Accredited School of Nursing or a Bachelor's degree in Nursing and 2 – 4 years of related experience.
License/Certification:
RN - Registered Nurse - State Licensure and/or Compact State Licensure required
Contract Apr 21, 2025 Healthcare Case Manager I to complete clinical assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers from the assessment. MUST reside in the state of Mexico in either of the following counties: Albuquerque area which would be Bernalillo, Sandoval and Valencia counties. This position is remote but requires field visits. Schedule M-F 8:00am-5:00pm MST.
KNOWLEDGE/SKILLS/ABILITIES
Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals.
Conducts telephonic, face-to-face or home visits as required.
Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly.
Maintains ongoing member case load for regular outreach and management.
Promotes integration of services for members including behavioral health care and long term services and supports to enhance the continuity of care for members.
May implement specific wellness programs i.e. asthma and depression disease management.
Facilitates interdisciplinary care team meetings and informal ICT collaboration.
Uses motivational interviewing and clinical guideposts to educate, support and motivate change during member contacts.
Assesses for barriers to care, provides care coordination and assistance to members to address concerns.
Collaborates with RN case managers/supervisors as needed or required
Case managers in the Behavioral Health and Social Science fields may provide consultation, resources and recommendations to peers as needed.
JOB QUALIFICATIONS
Required Education: Bachelor's or Master's Degree (preferably in a social science, psychology, gerontology, public health or social work or related).
Required Experience: 1-3 years in case management, disease management, managed care or medical or behavioral health settings.
Required License: Not required but if licensed, must be licensed unrestricted for NEW MEXICO in good standing.
Preferred License, Certification, Association:
Licensed Clinical Social Worker (LCSW), Advanced Practice Social Worker (APSW), Certified Case Manager (CCM), Certified in Health Education and Promotion (CHEP), Licensed Professional Counselor (LPC/LPCC), Respiratory Therapist, or Licensed Marriage and Family Therapist (LMFT).
Contract Apr 18, 2025 Healthcare JOB SUMMARY
We are seeking a Case Manager who lives in VIRGINIA (Central, Tidewater, NOVA, Roanoke/Charlottesville). Will work in remote and field settings supporting LTSS (Long Term Services and Support) and the Medicaid Population. Will be required to physically go to member’s homes and or Nursing Facilities to complete Face to Face assessments, participate in interdisciplinary care team meetings for our members and ensure members have care plans based on their concerns/health needs.
JOB ESSENTIALS
Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important. TRAVEL (30% or more) in the field to do member visits to the surrounding areas will be required. Tidewater and Central. This position is eligible for mileage reimbursement. The work schedule is Monday thru Friday 8:00AM to 5:00PM EST - No weekends.
KNOWLEDGE/SKILLS/ABILITIES
• Completes clinical assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers from the assessment.
• Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network.
• Conducts telephonic, face-to-face or home visits as required.
• Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly.
• Maintains ongoing member case load for regular outreach and management.
• Promotes integration of services for members including behavioral health care and long term services and supports to enhance the continuity of care for members.
• May implement specific wellness programs i.e. asthma and depression disease management.
• Facilitates interdisciplinary care team meetings and informal ICT collaboration.
• Uses motivational interviewing and clinical guideposts to educate, support and motivate change during member contacts.
• Assesses for barriers to care, provides care coordination and assistance to member to address concerns.
• Collaborates with RN case managers/supervisors as needed or required
• Case managers in Behavioral Health and Social Science fields may provide consultation, resources and recommendations to peers as needed
Required Years of Experience
1-3 years in case management, disease management, managed care or medical or behavioral health settings.
Required Licensure / Education
If license required for the job, license must be active, unrestricted and in good standing.
Must have valid driver’s license with good driving record and be able to drive within applicable state or locality with reliable transportation. Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program OR Bachelor's or Master's Degree (preferably in a social science, psychology, gerontology, public health or social work or related, Or Graduate from an Accredited School of Nursing. A Bachelor's Degree in Nursing is preferred.
Contract Apr 16, 2025 Administrative Job Summary
Data Capture Specialist is responsible for the accurate keying of information and scanning various documents.
Pay: 14.85/hour
Onsite Position - Marion, IN
Duties and Responsibilities
The responsibilities of the Data Capture Operator are outlined as follows and no intended to be all inclusive:
Accurately entering alphabetic and numeric data from electronic images with speed and accuracy utilizing software application to capture the appropriate data.
Reading, analyzing, and classifying documents based on certain assigned criteria.
Operating and maintaining scanning equipment, including processing documents through scanner and making appropriate adjustments to improve image capture.
Reviewing completed work and administering the company’s quality control procedures to ensure work is at or above required accuracy rates.
Assisting entire team in meeting daily and monthly KPIs and SLAs.
Following proper procedures, rules, and processes for data capture and quality assurance of data.
Utilizing appropriate and compliant safeguards to reasonably prevent the improper use or disclosure of confidential and protected information which may include Protected Health Information (PHI) and/or Personally Identifiable Information (PII) and reporting any concerns to manager.
Knowledge, Skills, and Abilities
High School Diploma or equivalent required.
Proficiency is MS Office (Word, Outlook, Teams, SharePoint).
Excellent typing skills—touch, 10 key, 45 wpm
Ability to pass reference checks, drug screen, and background checks.
Work Schedule
Monday: 9:00 a.m. - 6:00 p.m.
Tuesday: 9:30 a.m. - 5:30 p.m.
Wednesday through Friday: 9:00 a.m. - 5:30 p.m.
Contract Apr 15, 2025 Healthcare Job Title: Care Coordinator | Case Manager | Social Worker
Location: **Must be an Indiana Resident
Hours: Monday - Friday 8am-5pm
Job Summary:
The Care Coordinator (Case Manager - Nurse or Social Worker) must oversee the care coordination, complex case management functions for PathWays to Aging members who live in the community and who are not receiving Home and Community Based Services (HCBS) or designated as Nursing Facility Level of Care (NFLOC).
Primary Responsibilities:
• Identify, select, structure, and prioritize process improvement projects, ultimately implementing changes to meet program requirements
• Ensures standardized execution of workflow processes, including conducting performance audits, quality reviews, and compliance adherence
• 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
• Communicate with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members
• Advocate for patients and families as needed to ensure the patient’s needs and choices are fully represented and supported by the health care team
• Collaborates across Optum and UHG and interacted with Medical Directors, Site Directors, Senior Leaders, Network, Marketing, Account Management, Quality, Product, and other stakeholders
Required Qualifications:
• Resident of Indiana
• BSN with equivalent experience
• Registered Nurse or Social Worker with an unrestricted License in Indiana
• Experience working within the community health setting in a health care role
• Experience or knowledge of Indiana Medicaid, Medicare, Long term care
• Intermediate level of experience with Microsoft Word, with the ability to navigate a Windows environment
Preferred Qualifications:
• 3+ year of case management leadership experience within a healthcare industry
• Background in managed care
• Case Management experience
• Certified Case Manager (CCM)
• Experience / exposure with members receiving long term social supports
• Experience in utilization review, concurrent review and/or risk management
Contract Apr 15, 2025 Information Technology Job Title: Data Analyst 2
Location: Remote - Indiana
Hours: Monday-Friday 9-5pm ET, but flexible on early starts.
Position Purpose:
Integrates, conforms, profiles and maps data, and provides quality assurance oversight (data error detection and correction) on business processes where data is collected, stored, transformed, or used. Examines moderately complex data to optimize the efficiency and quality of the data being collected, resolves data quality problems, and collaborates with the business and ETL database developers to improve systems and database designs.
Summary:
The main function of a database analyst/programmer is to coordinate changes to computer databases, test, and implement the database applying knowledge of database management systems. A typical database analyst/programmer is responsible for planning, coordinating and implementing security measures to safeguard the computer database.
Job Responsibilities: Test programs or databases, correct errors and make necessary modifications. Modify existing databases and database management systems or direct programmers and analysts to make changes. Write and code logical and physical database descriptions and specify identifiers of database to management system or direct others in coding descriptions. Skills: Verbal and written communication skills, problem solving skills, customer service and interpersonal skills. Basic ability to work independently and manage one’s time. Basic knowledge of database management software.
Education/Experience: Associate's degree in computer programming or equivalent training required. 2-4 years experience required.
???????Technical Skills:
One or more of the following skills are desired.
Experience with Big Data; Data Processing
Experience with Data Manipulation; Data Mining
Experience with one or more of the following C# (Programming Language); Java (Programming Language); Programming Concepts; Programming Tools; Python (Programming Language); SQL (Programming Language)
Experience with Agile Software Development
Soft Skills:
Intermediate - Seeks to acquire knowledge in area of specialty
Intermediate - Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
Intermediate - Ability to work independently
Contract Apr 11, 2025 Healthcare
Substance Abuse Professional
Education / Certifications
• Certified Recovery Specialist (CRS) Certification
• certified peer support specialist (CPS)
• National Certified Addiction Counselor (NCAC)
• Master Addiction Counselor (MAC)
• National Certification in Nicotine and Tobacco Treatment (NCNTT)
• National Peer Recovery Support Specialist (NCPRSS)
• National Clinical Supervision Endorsement (NCSE)
• Certified Alcohol and Drug Counselor (CADC)
• Licensed Alcohol and Drug Counselor (LADC)
• Certified Addiction Counselor (CAC)
• Certified Associate Addiction Counselor (CAAC)
• Certified Master's Level Addiction Professional (MCAP)
• Certified Clinical Supervisor (CCS)
Experience
Completion of a specialized training program for recovery specialists.
Strong people skills, empathy, and the ability to remain calm under pressure are essential for this role.
Job Description
Responsible for providing support for individuals experiencing dependency of alcohol and/or drugs.
Job Details
Provide motivational support to individuals experiencing drug and/or alcohol dependency.
Engage individuals and conduct motivational interviewing to understand barriers and direct individuals to the appropriate level of care.
Assist individuals and families with understanding of how to utilize community services.
Provide recovery coaching to individuals and help them develop positive coping skills and resources to obtain and stay in treatment.
Link individuals to community support services and substance treatment services.
Pay
$20 an hour
Job Type
Part-time and Full-time positions available
Shift and schedule
Three shifts are available:
7 a.m. to 3 p.m.
3 p.m. to 11 p.m.
11 p.m. to 7 a.m.
Sunday through Saturday
Work Setting
Remote
Contract Apr 11, 2025 Healthcare
Registered Nurse
Education
Registered Nurse (RN) Degree
Have a valid RN State of Virginia License or Nurse Licensure Compact (NLC)
Experience
Training in crisis management techniques, trauma-informed care, and relevant experience working with individuals in crisis situations.
Strong interpersonal skills, empathy, and the ability to remain calm under pressure are essential for this role.
Nurses in this role need strong clinical skills, communication abilities, and the ability to work independently.
Job Description
Responsible for providing telephonic triage, health advice, assessing symptoms, and determining the appropriate course of action, which may include recommending self-care, scheduling appointments, or advising on emergency care.
Job Details
Educate individuals on the importance of nutrition, safety, and overall good health.
Provide knowledge and advice through our triage line.
Engage callers to assess and de-escalate uneasy situations in the least restrictive manner to ensure caller safety over the phone.
Report to assigned supervisor and actively seek consultation whenever necessary or requested by supervisor.
Build rapport with team members that fosters a team culture promoting values and vision.
Actively participate in quality improvement activities to promote continual growth and improvement in quality of services provided.
Completion of required documentation within established time frames.
Use of an Electronic Client Record, and additional call management software.
Maintain applicable licensure requirements.
Maintain intake notes, agency resource records, and documentation.
Maintain familiarity with, and adhere to, program policies and procedures.
Maintain confidentiality of privileged information and adhere to client privacy laws.
Document all critical incidents and utilize all agency procedures for proper documentation and record keeping.
Stay up to date on all required trainings.
Pay
Negotiable
Job Type
Part-time and Full-time positions available
Shift and schedule
Three shifts are available:
7 a.m. to 3 p.m.
3 p.m. to 11 p.m.
11 p.m. to 3 a.m.
Sunday through Saturday
Work Setting
Remote
Contract Apr 11, 2025 Healthcare
Licensed Mental Health Counselor (LMHC)
Education
A master's degree in counseling, clinical mental health counseling, psychology, social work, or related field.
Experience
Training in crisis management techniques, trauma-informed care, relevant experience working with individuals in crisis situations, substance abuse, depression, and anxiety.
Strong interpersonal skills, empathy, and the ability to remain calm under pressure are essential for this role.
Job Description
Provide counseling and therapy services to individuals dealing with various mental health issues, emotional challenges, and life transitions. Conduct assessments, develop treatment plans, and implement therapeutic interventions tailored to clients' needs and goals.
Job Details
Conduct assessments to understand clients' needs.
Collaborate with other healthcare professionals, such as psychiatrists, psychologists, and social workers, to provide comprehensive care.
Maintain accurate and confidential client records.
Adhere to ethical guidelines and legal regulations.
Participate in ongoing professional development to stay abreast of current research and best practices in the field.
Support clients in improving their mental health and well-being.
Facilitate positive life changes.
Advocate for clients' rights and access to resources within the community.
Engage callers to assess and de-escalate crises in the least restrictive manner to ensure caller safety over the phone.
Assist in the implementation of crisis safety plans.
As appropriate, provide emotional support, motivational interviewing, assessment or referral, linkage, and consultation with mental health service providers.
Elevate crisis calls based on standard operating procedures while also using clinical acumen and risk assessment skills.
Actively participate in quality improvement activities to promote continual growth and improvement in quality of services provided.
Continually engage in training and professional learning to build skills and collaborate with other team members.
Completion of required documentation within established time frames.
Use of an Electronic Client Record, and additional call management software.
Maintain any applicable licensure and/or certification requirements.
Maintain intake notes, agency resource records, and documentation.
Maintain familiarity with, and adhere to, program policies and procedures.
Maintain confidentiality of privileged information and adhere to client privacy laws.
Document all critical incidents and utilize all agency procedures for proper documentation and record keeping.
Stay up to date on all required trainings.
Other tasks as assigned.
Pay
To be discussed
Job Type
Part-time
Shift and schedule
Monday through Friday, 5 a.m. to 5 p.m. On-Call
Work Setting
Remote
Contract Apr 9, 2025 Healthcare The Community Well Care Coordinator must oversee the care coordination, complex case management functions for PathWays to Aging members who live in the community and who are not receiving Home and Community Based Services (HCBS) or designated as Nursing Facility Level of Care (NFLOC). The Care Coordinator must, at a minimum, be a registered nurse or similar medical professional with extensive experience in providing care coordination to members 60 years and older. This position does require local travel. This individual will work directly under the Health Services Directors to maintain the care coordination program. The individual will be responsible for overseeing care coordination teams, care plan development and care plan implementation. The Care Coordinator will be responsible for directing the activities of the care coordinators. These responsibilities extend to physical and behavioral health care services. This individual will work with the Heath Services Director, Service Coordinator Administrator, Medical Director, Provider and Member Services Managers, and with State staff as necessary, to communicate to providers and members. The Care Coordinator will provide input, as requested by the State, at State-level meetings.
Job Title: Community Well Care Coordinator
Location: Remote (Indiana) **Must be an Indiana Resident
Hours: Monday - Friday 8am-5pm
Pay: $38-48 hourly | Weekly pay
Primary Responsibilities:
Selects, develops, mentors and supports staff in designated department or region
Develops clear goals and objectives for performance management and effectively communicates expectations, and holds the team accountable for results
In order to meet the unique needs of our members, have an intimate understanding of the contractual requirements
Must travel locally
Identify, select, structure, and prioritize process improvement projects, ultimately implementing changes to meet program requirements
Ensures standardized execution of workflow processes, including conducting performance audits, quality reviews, and compliance adherence
• 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
Communicate with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members
Advocate for patients and families as needed to ensure the patient’s needs and choices are fully represented and supported by the health care team
Participates in training and coaching of direct reports as needed
Conducts bi-annual field visits with direct reports to observe, provide areas of teaching, address issues and concerns and foster a good working relationship
Collaborates across Optum and UHG and interacted with Medical Directors, Site Directors, Senior Leaders, Network, Marketing, Account Management, Quality, Product, and other stakeholder
Required Qualifications:
Resident of Indiana
BSN with equivalent experience
Registered Nurse with an unrestricted License in Indiana
Experience working within the community health setting in a health care role
Driver's License
Experience or knowledge of Indiana Medicaid, Medicare, Long term care
Experience coaching or mentoring staff
Intermediate level of experience with Microsoft Word, with the ability to navigate a Windows environment
Preferred Qualifications:
• 3+ year of case management leadership experience within a healthcare industry
• Background in managed care
• Case Management experience
• Certified Case Manager (CCM)
• Experience / exposure with members receiving long term social supports
• Experience in utilization review, concurrent review and/or risk management
PME is an equal opportunity employer. We prohibit discrimination and harassment against any applicant or employee based on any legally recognized basis, including, but not limited to: veteran status, uniformed servicemember status, race, color, religion, sex, sexual orientation, gender identity, age (40 and over), pregnancy, national origin or ancestry, citizenship status, physical or mental disability, genetic information (including testing and characteristics) or any other category protected by federal, state or local law.
Contract Apr 4, 2025 Customer Service Responsible for responding to customer inquiries. Inquiries may be non-routine and require deviation from standard screens, scripts, and procedures. Performs research as needed to resolve inquiries. Reviews and adjudicates claims and/or non-medical appeals. Determines whether to return, deny or pay claims following organizational policies and procedures.
Responsibilities:
Ensures effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries. Handles situations which may require adaptation of response or extensive research. Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines.
Examines and processes claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines. Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes. Ensures claims are processing according to established quality and production standards.
Identifies complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refers these to a lead or manager for resolution. Identifies and reports potential fraud and abuse situations.
$16.00/hour
Monday-Friday - 8am-4:30pm
6-week training period
Requirements:
High School Diploma or equivalent (Required)
2 years of customer service experience including 1-year claims or appeals processing OR bachelor's degree in lieu of work experience (Required)
Microsoft Office Experience
Good verbal and written communication skills
Strong customer service skills
Good spelling, punctuation and grammar skills
Basic business math proficiency
Ability to handle confidential or sensitive information with discretion
Direct Hire Apr 2, 2025 Healthcare Medical Director responsible for serving as the primary liaison between administration and medical staff. Assures the ongoing development and implementation of policies and procedures that guide and support the provisions of medical staff services. Maintains a working knowledge of applicable national, state, and local laws and regulatory requirements affecting the medical and clinical staff.
JOB DUTIES (Main duties & responsibilities of the role):
• Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to members, targeting improvements in efficiency and satisfaction for patients and providers, as well as meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.
• Develops and implements a Utilization Management program and action plan, which includes strategies that ensure a high quality of patient care, ensuring that patients receive the most appropriate care at the most effective setting. Evaluates the effectiveness of UM practices. Actively monitors for over and under-utilization. Assumes a leadership position relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity.
• Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse incidents and quality of care concerns. Participates in preparation for NCQA and URAC certifications. Develops and provides leadership for NCQA-compliant clinical quality improvement activity (QIA) in collaboration with the clinical lead, the medical director, and quality improvement staff.
• Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements.
• Reviews quality referred issues, focused reviews and recommends corrective actions.
• Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.
• Attends or chairs committees as required such as Credentialing, P&T and others as directed by the Chief Medical Officer.
• Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the denial process.
• Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care.
• Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care.
• Ensures that medical protocols and rules of conduct for plan medical personnel are followed.
• Develops and implements plan medical policies.
• Provides implementation support for Quality Improvement activities.
• Stabilizes, improves and educates the Primary Care Physician and Specialty networks. Monitors practitioner practice patterns and recommends corrective actions if needed.
• Fosters Clinical Practice Guideline implementation and evidence-based medical practice.
• Utilizes IT and data analysts to produce tools to report, monitor and improve Utilization Management.
• Actively participates in regulatory, professional and community activities.
REQUIRED EDUCATION:
• Doctorate Degree in Medicine
• Board Certified or eligible in a primary care specialty
REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:
3+ years relevant experience, including:
• 2 years previous experience as a Medical Director in a clinical practice.
• Current clinical knowledge.
• Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen.
• Knowledge of applicable state, federal and third party regulations
REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:
Current state Medical license without restrictions to practice and free of sanctions from Medicaid or Medicare.
PREFERRED EDUCATION:
Master’s in Business Administration, Public Health, Healthcare Administration, etc.
PREFERRED EXPERIENCE:
• Peer Review, medical policy/procedure development, provider contracting experience.
• Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines.
• Experience in Utilization/Quality Program management
• HMO/Managed care experience
PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:
Board Certification (Primary Care preferred)
Contract To Hire Apr 2, 2025 Accounting Duties:
Examine Admission and Discharge Episode of Care Records
Ensure Adequate Clinical Documentation
Verify Level of Care
Ensure Compliance with MLA Billing Procedures and Standards
Prepare, Code and File Claims
Track Claims Status, Approvals
Ensure EOB Accuracy
Ensure Accurate Payment Posting
Ensure Accurate Data Entry
Process Denials and Appeals
Perform such other and further duties as assigned by the MLA Revenue Cycle Director
Qualifications:
· Proven working experience as a Medical Accounts Receivable Specialist or similar role.
· TRICARE Health Plan billing experience (Must have)
· Knowledge of billing procedures and collection techniques
· Familiarity with medical terminology and healthcare regulations.
· Proficiency with MS Office and databases.
· Excellent communication and data entry skills.
· Attention to detail and problem-solving ability.
· Understanding of medical coding and billing software.
· High school diploma; degree in Business Administration or related field is a plus.
Direct Hire Apr 1, 2025 Healthcare Physician III must be SOUTH CAROLINA board licensed in Family Medicine. SC residency is required. The scope of practice is Family Medicine. Family Medicine Board Certification is required. Chart Reviews will be completed via Telehealth. The Physician will be required to complete 2 hours per assigned Nurse Practitioner per month for a total of 8 hours per month.
Position will require the following:
Conduct a monthly Quality Chart reviews of a 10% representative sample or a minimum of two (2) chart reviews, whichever is greater.
Comply with state requirements to meet with assigned NPs to review and discuss chart documentation and quality of care.
Be available by phone or electronic means of communication during the NP’s working hours (40 hours per week).
Serve as a supervising and collaborating physician in accordance with applicable law and terms and conditions of the NP Collaborative Practice Protocol Agreement.
Liability insurance will be provided for physicians’ claims arising solely and exclusively from Physician’s delivery of professional services relating to Physician’s Supervision and Collaboration services provided to NP’s.
Liability insurance will be provided for physicians’ claims arising solely and exclusively from Physician’s delivery of professional services relating to Physician’s Supervision and Collaboration services provided to NP’s
All Supervising physician’s responsibilities can be completed telephonically.
Requirements
Physician must be SC board licensed in family medicine. SC residency is required.
Physician III must be SOUTH CAROLINA board licensed in Family Medicine. SC residency is required. The scope of practice is Family Medicine. Family Medicine Board Certification is required. Chart Reviews will be completed via Telehealth. The Physician will be required to complete 2 hours per assigned Nurse Practitioner per month for a total of 8 hours per month.
Position will require the following:
Conduct a monthly Quality Chart reviews of a 10% representative sample or a minimum of two (2) chart reviews, whichever is greater.
Comply with state requirements to meet with assigned NPs to review and discuss chart documentation and quality of care.
Be available by phone or electronic means of communication during the NP’s working hours (40 hours per week).
Serve as a supervising and collaborating physician in accordance with applicable law and terms and conditions of the NP Collaborative Practice Protocol Agreement.
Liability insurance will be provided for physicians’ claims arising solely and exclusively from Physician’s delivery of professional services relating to Physician’s Supervision and Collaboration services provided to NP’s.
Liability insurance will be provided for physicians’ claims arising solely and exclusively from Physician’s delivery of professional services relating to Physician’s Supervision and Collaboration services provided to NP’s
All Supervising physician’s responsibilities can be completed telephonically.
Requirements
Physician must be SC board licensed in family medicine. SC residency is required.
Contract Mar 17, 2025 Information Technology Job Title: Senior Software Engineer
Location: Remote USA
Job Description:
We are seeking a skilled COBOL/2E Developer with a minimum of 4 years of hands-on experience to join our dynamic team. The ideal candidate will have a strong background in both front-end (screen) and back-end (business logic) development, with a deep understanding of COBOL. Experience with PBM/RxClaim and additional knowledge of development tools and modern IDEs is a big plus.
In this role, you will be responsible for designing entities, defining SQL objects, debugging COBOL code, and working with change control tools on the IBMi platform. If you're a problem solver with a passion for working on complex business logic, we encourage you to apply!
Key Responsibilities:
SQL & DDL: Define SQL tables and SQL View objects within the SYNON model. Utilize strong experience in Data Definition Language (DDL) and SQL to support system functionality.
COBOL Debugging: Read and debug COBOL program code running on the IBMi platform to ensure functionality and performance.
Change Control: Work with Aldon/ACMS or similar change control tools on the IBMi for effective version control and deployment.
Business Logic: Develop and optimize business logic and heavy lifting operations in back-end systems.
PBM/RxClaim: Leverage your knowledge of PBM/RxClaim to integrate and optimize solutions in the health industry (experience preferred).
Development Tools: Utilize VS Code, RDi, or other modern IDE tools to ensure effective development and debugging.
Other Tools: Exposure to COBOL ILE, X-Analysis, ROBOT Scheduler, and REST API is a plus.
Required Skills & Qualifications:
(4+ years experience) on the IBMi platform
Proficient in SQL (DDL, SQL tables, and Views).
Solid understanding of COBOL program code, including the ability to read and debug code on the IBMi platform.
Experience with Aldon/ACMS or similar change control tools.
Knowledge of PBM/RxClaim is a plus.
Familiarity with VS Code, RDi, or other modern IDEs.
Experience with COBOL ILE, X-Analysis, ROBOT Scheduler, and REST API is highly desirable.
Strong analytical and problem-solving skills with the ability to work independently and in a team environment.
Additional Preferences:
RxClaim experience: Preferred but not mandatory.
VS Code/RDi: Familiarity with modern IDEs will be an added advantage.
X-Analysis and ROBOT Scheduler experience is a bonus.
COBOL ILE knowledge is a plus.
Ability to work in a collaborative, fast-paced environment.
Contract Mar 4, 2025 Administrative Title: Quality Analyst
Location: Indiana
Hours: Monday-Friday 8am-5pm
Pay: $19.50hr **weekly pay**
Job Description
• Responsible for activities involving quality assurance and compliance with all applicable company and regulatory requirements.
• Adheres to the QMMP (Quality Metric Management Plan).
• Conducts quality performance audits by evaluating trainee output.
• Reviews/analyzes data and documentation.
• Provides analytical reports and makes process improvement recommendations.
• Implements key process improvement efforts and influences cross-functional efforts.
• Assists in the development of systematic approaches for assuring high quality services.
• Provides feedback based on approved process documentation to improve key activities of the organization.
• Some travel may be required.
• All other duties as assigned.
• Completing SPR’s for the Indiana Eligibility Project trainees.
Requirements
• Extensive knowledge of the Indiana Public Assistance Programs (Supplemental Nutrition Assistance Program (SNAP), Medicaid, and Temporary Assistance for Needy Families (TANF) policy and guidelines including IEDSS online help.
• Experience using IEDSS.
Education and Experience (Preferred)
• Associate degree.
• Typically requires a minimum of 1 year of Indiana Eligibility Case Processing.
• Ability to synthesize and analyze complex information.
• Strong ability to read and interpret written information.
• Strong oral communication and group presentation skills.
• Clear and professional written communication.
• Proficiency in Microsoft Applications (Word, Excel, Outlook).
PME is an equal opportunity employer. We prohibit discrimination and harassment against any applicant or employee based on any legally recognized basis, including, but not limited to: veteran status, uniformed servicemember status, race, color, religion, sex, sexual orientation, gender identity, age (40 and over), pregnancy, national origin or ancestry, citizenship status, physical or mental disability, genetic information (including testing and characteristics) or any other category protected by federal, state or local law.
