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 Apr 1, 2025 Healthcare Care Review Clinician II to work with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities. This position is fully remote. To qualify you MUST have an active, unrestricted WASHINGTON STATE licensure (RN, LPN, LCSW, LPCC or LMFT). The work schedule is Monday-Friday, 9-5 PST or possibly Tuesday-Saturday PST.
Essential Functions:
Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review.
Assesses services for members to ensure optimum outcomes and compliance with all state and federal regulations and guidelines.
Provides concurrent review and prior authorizations.
Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
Participates in interdepartmental integration and collaboration to enhance the continuity of care for members including Behavioral Health and Long-Term Care.
Knowledge/Skills/Abilities:
Demonstrated ability to communicate, problem solve, and work effectively with people.
Knowledge of applicable state, and federal regulations.
In-depth knowledge of Interqual and other references for length of stay and medical necessity determinations.
Experience with NCQA.
Computer Literate (Microsoft Office Products).
Excellent verbal and written communication skills.
Required Education:
Completion of an accredited Registered Nursing program.
Required Experience: Minimum 2-4 years of clinical practice. Preferably hospital nursing, utilization management, and/or case management.
Required Licensure/Certification:
Active, unrestricted State Nursing (RN or LVN) WA license in good standing.
Contract Apr 1, 2025 Healthcare Care Review Clinician II (RN or LVN) is the clinical support for the COC and Community Support Teams. This nurse will serve as a clinical reviewer to help determine whether requests meet COC criteria or Community Support Criteria. Will create authorizations and send for MD review when appropriate while following the UM process. Will complete phone calls to providers when applicable. This position is FULLY remote, but ***MUST be a licensed RN or LVN in the state of CALIFORNIA. The work schedule will be M- F 8am to 5pm PST.
JOB ESSENTIALS
• Provides concurrent review and prior authorizations (as needed) according to Molina policy for members as part of the Utilization Management team.
• Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
• Participates in interdepartmental integration and collaboration to enhance the continuity of care for members including Behavioral Health and Long-Term Care.
• Maintains department productivity and quality measures
• Assists with mentoring of new team members.
• Completes assigned work plan objectives and projects on a timely basis.
• Maintains professional relationships with provider community and internal and external customers.
• Consults with and refers cases to medical directors regularly, as necessary.
KNOWLEDGE/SKILLS/ABILITIES
Nurse (LVN or RN) who must be licensed in California.
Strong inpatient and outpatient medical and hospital analytical experience is needed.
Excellent computer multi-tasking skills and good productivity is essential for this fast-paced role.
Strong computer skills, being able to toggle back and forth and use multiple databases.
Good analytical thought process is important to be successful in this role, this is a metric-based environment. Work independently and handle multiple projects simultaneously. Experience with NCQA
Required Education
Required Education: Nursing Degree with RN or LVN licensure
Required Experience
3-5 years’ experience in a MCO setting
MCO experience in UM
Contract Apr 1, 2025 Healthcare Care Review Clinician I (RN) to work with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities. This position is FULLY remote, but ***MUST be a licensed RN, LPN LCSW or LPC. The work schedule will be Tuesday- Saturday 8am to 5pm EST.
JOB ESSENTIALS
• Provides concurrent review and prior authorizations (as needed) according to Molina policy for members as part of the Utilization Management team.
• Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
• Participates in interdepartmental integration and collaboration to enhance the continuity of care for members including Behavioral Health and Long-Term Care.
• Maintains department productivity and quality measures
• Assists with mentoring of new team members.
• Completes assigned work plan objectives and projects on a timely basis.
• Maintains professional relationships with provider community and internal and external customers.
• Consults with and refers cases to medical directors regularly, as necessary.
KNOWLEDGE/SKILLS/ABILITIES
• Demonstrated ability to communicate, problem solve, and work effectively with people.
• Excellent organizational skill with the ability to manage multiple priorities.
• Work independently and handle multiple projects simultaneously.
• Knowledge of applicable state, and federal regulations.
• In depth knowledge of Interqual and other references for length of stay and medical necessity determinations.
• Experience with NCQA
Required Education
Required Education: Nursing Degree with RN licensure
Required Experience
1-2 year Utilization Management experience in a HP setting
BH service background and/or MCO experience in UM
Required License
Required Licensure / Education: Licensure required is a State License Registered Nurse – RN license
Contract Apr 1, 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: Curry, De Baca, Quay or Roosevelt county. This position 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: 1-2 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 Mar 28, 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 Mar 26, 2025 Other Area(s) 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
Contract Mar 24, 2025 Administrative The data collection staff will assist the Department in its statutory responsibilities related to sex and violent offender registration.
Duties:
Incumbent enhances criminal history records by researching and collecting court documents, and by entering this data into a tracking system. This position requires the incumbent to collect court documentation from within Indiana, other states, military and federal jurisdictions, etc., to assist in registration efforts for the State of Indiana. Incumbent reports to the Sex and Violent Offender Registration and Victim Services Division of the Indiana Department of Correction. This position is Monday through Friday, in office.
Essential Functions:
Research and collect court documents and sentencing information
Analyze and interpret documents collected
Communicate with local, state, and federal law enforcement agencies
Enter data into a designated tracking system
Perform related duties as assigned by division staff
Job Requirements:
Broad experience with data collection and data entry
Broad knowledge of the Indiana Code
Thorough knowledge of the Indiana Department of Correction, as well as all levels of the Criminal Justice System
Experience and comfort with court documents and legal jargon
Broad knowledge of national criminal justice resources
Excellent written, verbal, and interpersonal communication skills
Strong organizational and time management skills
Ability to read and process data including information on crimes that is detailed, thorough, and contains sensitive material
Ability to establish cooperative working relationships with department staff and external agency staff
Minimum Qualifications:
Legal research experience and skills
Bachelor’s Degree required
Master’s Degree preferred
Equivalent work experience may also be considered
Difficulty of Work:
Incumbent must be able to handle multiple, complex tasks and make good decisions based on his or her knowledge and understanding of each specific question and assignment
Incumbent must use multiple methods in accomplishing an end result or outcome of a particular task and must be timely and accurate in completion of all tasks
Incumbent work must be accurate - consequences of inaccurate data include a negative public perception of the Department and potential public safety risks to the communities
Incumbent works independently with work being reviewed on a periodic basis for accuracy, compliance with policy, and overall project goals
Personal Work Relationships:
Incumbent must maintain working relationships with all Department personnel and external stakeholders to discuss projects related to their needs
Contract Mar 21, 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 Mar 20, 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
Contract Mar 20, 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
Contract Mar 17, 2025 Information Technology Job Title: SYNON/2E Developer
Location: Remote USA
Job Description:
We are seeking a skilled SYNON/2E Developer with a minimum of 3 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 the SYNON/2E environment. 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:
SYNON/2E Development: Design entities, define front-end (screen) and back-end (business logic) functions within the SYNON/2E environment.
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:
At least 3 years of hands-on experience with SYNON/2E development, including both screen and backend functions.
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.
Contract Feb 27, 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 Feb 11, 2025 Healthcare Care Review Clinician I (RN or LPN) to work with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities. This position is FULLY remote, but ***MUST reside in New Mexico. The work schedule will be M-F 8:30am-5:00pm MST. Some weekends may be required.
Essential Functions:
Provides concurrent review and prior authorizations (as needed) according to policy for members as part of the Utilization Management team.
Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
Participates in interdepartmental integration and collaboration to enhance the continuity of care for members including Behavioral Health and Long-Term Care.
Maintains department productivity and quality measures.
Knowledge/Skills/Abilities:
Demonstrated ability to communicate, problem solve, and work effectively with people.
Excellent organizational skill with the ability to manage multiple priorities.
Knowledge of applicable state, and federal regulations.
In-depth knowledge of Interqual and other references for length of stay and medical necessity determinations.
Experience with NCQA.
Required Education
Required Education: Nursing Degree with RN or LPN licensure
Required Experience
3-5 years Utilization Management experience in a HP setting. Minimum 0-2 years of clinical practice. Preferably hospital nursing, utilization management, and/or case management.
Required License
Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing.
Contract Jan 21, 2025 Healthcare RN Case Manager to conduct UAS Assessments to support care management. The position will be a field position in Boroughs: Bronx/ Westchester/ Manhattan, NY visiting nursing and assisted living facilities. Schedule will be M-F 8:30AM-5PM. ***RN UAS Certified highly preferred. Bilingual in Spanish or Bengali is highly preferred.
Essential Functions/Responsibilities:
UAS Certified RN licensed in the state of NY.
Conduct face to face assessments of members’ functional status, medical, behavioral, psychosocial and community resource needs.
Provides the Interdisciplinary Care Team (ICT) with assessment information and acts as facilitator to ensure that members’ needs are met.
Develop an ICP/PCSP based on members’ clinical, behavioral, and social needs that addresses barriers to care.
Competently assesses members’ health status and ensures that member is receiving all necessary medical and supportive services.
Manage care transitions through effective and timely communication necessary for member care and discharge planning.
Clarifies SWH plan medical benefits, policies and procedures for members, providers and community-based agencies.
Maintain a comprehensive working knowledge of community resources, payer requirements, and network services for target population.
Required Education:
Bachelor's Degree (a combination of experience and education will be considered in lieu of degree).
Required Licensure/Certification:
NY State RN License in good standing.RN Case Manager to conduct UAS Assessments to support care management. The position will be a field position in Boroughs: Bronx/ Westchester/ Manhattan, NY visiting nursing and assisted living facilities. Schedule will be M-F 8:30AM-5PM. ***RN UAS Certified highly preferred. Bilingual in Spanish or Bengali is highly preferred.
Essential Functions/Responsibilities:
UAS Certified RN licensed in the state of NY.
Conduct face to face assessments of members’ functional status, medical, behavioral, psychosocial and community resource needs.
Provides the Interdisciplinary Care Team (ICT) with assessment information and acts as facilitator to ensure that members’ needs are met.
Develop an ICP/PCSP based on members’ clinical, behavioral, and social needs that addresses barriers to care.
Competently assesses members’ health status and ensures that member is receiving all necessary medical and supportive services.
Manage care transitions through effective and timely communication necessary for member care and discharge planning.
Clarifies SWH plan medical benefits, policies and procedures for members, providers and community-based agencies.
Maintain a comprehensive working knowledge of community resources, payer requirements, and network services for target population.
Required Education:
Bachelor's Degree (a combination of experience and education will be considered in lieu of degree).
Required Licensure/Certification:
NY State RN License in good standing.
