Professional Management Enterprises, Inc.

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Contract Jul 18, 2024 Administrative We are in an immediate need for a Correspondence Coordinator. This person will need to have project management or strong administrative type skills. They’re re going to own the Correspindence Coordination and be held to continuous process improvement requirements.  They will need to report to our Meridian Street office daily.  This is not a remote position.   Requirements: Manage data. Understand process improvement. Convert letters to the appropriate formats (large print, alternate languages, braille) using templates and software, then print and mail them within the required turn around time. Keep track of returned mail (update a spreadsheet, then mail when new demographic information is located or shred after a defined period of time. Clearly and professionally communicate with cross functional teams and stakeholders( both verbally and in writing). Be able to work independently. High School Diploma or equivalent
Contract Jul 17, 2024 Call Center Professional Management Enterprises is seeking a Customer Care Representative to join our call center team! As a Customer Care Representative, you will act as a trusted advisor and educator on health care related inquiries. You will guide our customers to a better healthcare experience, working every day to make healthcare easy with the service you provide. Job Title:  Customer Care Representative Location:  Indianapolis, Indiana Must be within a 50-mile radius Pay:  $15hr (Weekly Pay) In-Person Training (8 Weeks) Training Work Hours: Monday-Friday, 9am-5:30pm Work Hours:  Monday-Friday, 10am - 6:30pm Duties and Responsibilities: Responds to customer questions via telephone and written correspondence regarding insurance benefits, provider contracts, eligibility and claims. Analyzes problems and provides information/solutions. Operates a PC/image station to obtain and extract information; documents information, activities and changes in the database. Thoroughly documents inquiry outcomes for accurate tracking and analysis. Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner. Researches and analyzes data to address operational challenges and customer service issues. Provides external and internal customers with requested information. Under immediate supervision, receives and places follow-up telephone calls / e-mails to answer customer questions that are routine in nature. Uses computerized systems for tracking, information gathering and troubleshooting. Requires limited knowledge of company services, products, insurance benefits, provider contracts and claims. Seeks, understands and responds to the needs and expectations of internal and external customers. Required to meet department goals. Skills: Experience in customer service is a plus Ability to navigate multiple computer screens at a time. Ability to provide quality customer service while multi-tasking is a plus. Requirements: Requires a HS diploma or equivalent; up to 1 year of previous experience in an automated customer service environment; or any combination of education and experience, which would provide an equivalent background. Must have a private area to work closed off from others. Can not be responsible for minors or be a primary caretaker for another person during working hours. Must live within a 50 miles radius of Indianapolis, Indiana
Contract Jul 17, 2024 Other Area(s) Care Engagement Specialist to be responsible for supporting the organization’s goals of obtaining health needs screenings, scheduling preventive service appointments, and educating members on plan benefits and services. Provide members with educational materials and carry out strategies to increase health care adherence and reduce barriers to care. MUST reside in Indiana. Schedule: Mon-Fri 9am-6pm Remote Job Responsibilities: Make outbound or receive inbound calls from members to schedule doctor appointments, assist members that need to complete Health Needs Screenings or make payments to become eligible for enhanced benefits. Influence members to take advantage of additional benefits. Educate members on utilization of Emergency Departments in non-emergent conditions. Identify and overcome barriers for members to complete needed health screenings, obtain needed services or make payments to secure enhanced benefits. Review each member profile prior to outreach to identify areas of opportunity. Participate in continuous quality improvement initiatives to ensure department and company goals are met. Review and analyze data for call reports to make adjustments as needed. Act as a secondary resource for the Member Services or Provider Services call centers. Education/Experience: High School diploma or equivalent and 0-2 years of sales experience in a call center or other high-pressure sales environment. Bilingual in Spanish and English preferred.  
Contract Jul 17, 2024 Other Area(s) Seeking Case Manager I with LTSS experience to be responsible for health care management and coordination of members. MUST reside in the Lee, FL area. This is a work from home position but will require face-to-face visits in members’ home/Assisted Living Facilities or Nursing Home Facilities. Schedule M-F 8:30am-5:00pm. Day to Day Responsibilities: Access resources to assist with special health care needs. Assist caregivers with day-to-day processes. Scheduling appointments every 90 days or as needed. Arrange for transportation when required. Identify any gaps in care or health care needs. Coordinate moving from member from one setting to another including being discharged from the hospital. Assess eligibility for long-term care services and support. Connect with community resources as well as finding services from additional resources, including community and social services programs. Arrange for services with a primary care provider (PCP), family members, caregivers and any other identified provider. Must Have Skills: Excellent communication skills. Strong technical skills (utilizing multiple programs at the same time) along with competency in Microsoft applications (Outlook, Teams, Excel, etc.). Strong organizational and interpersonal skills. Required Years of Experience: 0-2 years of case management experience. No licensure is required, but if licensed, must be active and in good standing. Previous case management or MCO experience is a plus. Required Licensure / Education: Bachelor’s in related fields Nursing, Social Work, Healthcare Administration degree in nursing, social sciences, social work or related field or Bachelor or master’s degree prepared in human-services related field.  
Contract To Hire Jul 17, 2024 Information Technology Responsible for programming on specific application subsets of the company's application portfolio, participating in all phases of the development and maintenance life cycle, typically for an assigned business unit, client program, or corporate department and utilizing various customer technology platforms. Primary duties may include, but are not limited to: Maintains active relationships with customers to determine business requirements and leads requirements gathering meetings. Owns the change request process and may coordinate with other teams as necessary. Develops and owns list of final enhancements. Develops and defines application scope and objectives and prepares technical and/or functional specifications from with programs will be written. Performs technical design reviews and code reviews. Ensures unit test is completed and meets the test plan requirements, system testing is completed and system is implemented according to plan. Assesses current status and supports data information planning. Coordinates on-call support and ensures effective monitoring of system. Maintains technical development environment. Mentors others and may lead multiple or small to medium sized projects. Facilitates group sessions to elicit complex information on requirements clarification, design sessions, code reviews and troubleshooting issues. Supports vendor evaluation. Requires BA/BS degree in related field or technical institute training; 5 or more years related experience; multi platform experience; , expert level experience with business and technical applications, or any combination of education and experience, which would provide an equivalent background. Incumbent should also have the ability to mentor others, lead multiple small projects and provide troubleshooting support. Multi dimensional required. Multi database and/or multi language preferred. • CRM - Extensive IT experience in analysis, design, development and implementation of Client/Server, Web-based and CRM applications. • Siebel – extensive experience in development, data migration, configuration, integration, and customization of Siebel IP 24.x using Siebel Tools, Siebel Workflow, Assignment Manager, EIM, EAI, eScript, Smart Scripts, Task UI, Siebel CTI and Siebel Test Automation. • Database - Good working knowledge of Oracle Database. • Working knowledge of distributed microservices architecture with focus on RESTful APIs and Webservices based on industry standards is strongly preferred. • Siebel CTI Expertise – Proficiency in Siebel CTI using Gplus adapter and Genesys cloud for both voice and Web Chat operations is a must-have. • Working experience in implementing complex flows using Task UI integrating with Siebel CTI is preferred. • Working knowledge of customizing Siebel CRM application using Siebel Open UI framework along with JavaScript, CSS, HTML5, XSLT is strongly preferred. • Working experience in implementing CI/CD pipeline for automated deployments of Siebel artifacts using Jenkins is preferred. • Working experience in cloud technologies and platforms such as AWS strongly preferred. • Strong critical thinking, problem solving, and effective decision-making strongly preferred. • Ability to articulate objectives, problem statements and success criteria strongly preferred. • Ability to influence leadership on the need of a particular technological or business solution strongly preferred. • Knowledge on LLM tools is an added advantage. Monday-Friday, 08:00 am to 5:00 pm EST - Some weekend support but less than 1% of time.
Contract Jul 16, 2024 Administrative PME is looking for a Part time Mail Clerk to handle, sort and distribute envelopes and packages. Your goal will be to ensure our mail reaches its recipients in good condition. Required Hours: Monday, Wednesday, Friday, and Saturday - 7 am-finish (5 hours a day roughly for 4-6 weeks of work) Pay: $18/hour  Responsibilities Sign for incoming registered or certified mail Sort mail by department, location or category (e.g. bills, notices, personal) Stamp and record date of receipt and sender’s name Keep records of incoming packages, including their weight, return address and description. Collect and prepare correspondence to be mailed (e.g. applying appropriate stamps, verifying addresses) Correct and reforward misdirected mail Arrange for express delivery when needed Distribute mail to individuals or departments Track mailroom supplies (e.g. stamps, envelopes, address labels) Skills Proven experience as a Mail Clerk or Office Clerk Experience with mail sorting and postage meter machines is a plus Good computer skills Well-organized, with sharp attention to detail Ability to work under pressure Good communication and literacy skills Requirements: Must be able to pass background check
Contract Jul 15, 2024 Other Area(s) Medical Reviewer I, licensed LPN, LVN or Social Worker to perform medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. MUST reside local to COLUMBIA, SC. Schedule: M-F 8am to 5pm EST. Onsite training for the first 3 weeks, then work from home.   Documents decisions using indicated protocol sets or clinical guidelines. Provide support and review of medical claims and utilization practices. Provide support of medical claims review and utilization review practices. Performs authorization process, ensuring coverage for appropriate medical services. Utilizes allocated resources to back up review determination. Conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs. Performs screenings/assessments and determines risk via telephone. Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services. Required Skills and Abilities: Working knowledge of word processing software. Good judgment skills. Demonstrated customer service and organizational skills. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Required Software and Tools: Microsoft Office. Working knowledge of spreadsheet and database software. Knowledge of Microsoft Excel, Access, or other spreadsheet/database software. Required Education: Bachelor's degree - Social Work, OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing. Required Experience: 2 years clinical experience. Required Licenses and Certificates: Active, unrestricted LPN/LVN licensure from the United States and in the state of SC, OR, active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted LBSW (Licensed Bachelor of Social Work) licensure from the United States and in the state of hire. Preferred Education: Associate Degree- Nursing OR Graduate of an Accredited School of Nursing. Preferred Licenses and Certificates: Active, unrestricted RN licensure from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).  
Contract Jul 9, 2024 Healthcare Job Title: SSB Nurse Medical Mgmt I Location: Remote *Must be Indiana Resident Work Schedule: 40 hours a week maximum to be worked in five eight-hour shifts across Monday through Saturday. 8AM to 5PM EST. Team currently works about 1 Saturday every 4-5 weeks but could do more Saturdays upon request.  JOB SUMMARY: Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. JOB DUTIES AND RESPONSIBILITIES: Primary duties may include, but are not limited to: Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Applies clinical knowledge to work with facilities and providers for care coordination. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract. Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process. Collaborates with providers to assess member's needs for early identification of and proactive planning for discharge planning. Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications. Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards. REQUIRED SKILLS: Utilization Management and/or Milliman Care Guideline experience is preferred. Acute inpatient nursing experience is required. Must be comfortable working in a virtual environment with strong IT/computer skillset to include Excel, Microsoft Outlook, Microsoft Teams. Fast learner who can adapt to frequent process changes. Excellent attendance. EDUCATION/EXPERIENCE: Requires an AS/BS in nursing; 2 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in applicable state(s) required. 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 Jul 8, 2024 Healthcare 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.  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 No fields configured Please contact your admin to configure this card
Contract Jul 3, 2024 Healthcare The Community Well Care Coordination Manager 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 Coordination Manager 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 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 Coordination Manager 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 Coordination Manager will provide input, as requested by the State, at State-level meetings. Primary Responsibilities: •    Selects, manages, 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 •    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 stakeholders Required Qualifications: •    Resident of Indiana •    BSN or BSW with equivalent experience •    Registered Nurse 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 •    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  
Contract Jul 3, 2024 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 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. Primary Responsibilities: •    Selects, manages, 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 •    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 stakeholders 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 •    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 Jul 3, 2024 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 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. Primary Responsibilities: •    Selects, manages, 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 •    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 stakeholders 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 •    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.
Direct Hire Jul 2, 2024 Administrative Job Summary Data Capture Specialist is responsible for the accurate capture of the alphabetic, numeric, or symbolic data from electronic images and/or source documents according to the custom developed software application including repair of incorrect data resulting from OCR process (optical character recognition results). Pay Rate: $14.85hr (Weekly Pay) Full time Schedule Monday (9:00 am – 6:00 pm) Tuesday (9:30 am – 5:30 pm) Wednesday – Friday (9:00 am – 5:30 pm) Part time Schedule options: Monday (1:00pm - 6:00pm) Tuesday - Friday (1:00pm - 5:30pm)                 Or Monday (9:00am - 6:00pm) Wednesday, Friday (9:00am - 5:30pm) Duties and Responsibilities  The responsibilities of the Data Capture Specialist are outlined as follows and no intended to be all inclusive: Enters alphabetic, numeric, or symbolic data from electronic images utilizing the Captiva Input Accel software application to capture the appropriate data including repairing any rejected characters as a result of the OCR function. Routes electronic data to next work flow process when completed or in the case of undefined documents or documents that are not able to be indexed, may need to route electronic image to next work flow process. Responds to inquiries regarding the status of data capture, rejected character repair, or quality assurance phases of the data capture process. Follows proper procedures, rules, and processes for data capture and quality assurance of the data as outlined in the procedures manual. Utilizes appropriate and compliant safeguards to reasonably prevent the use or disclosure of confidential and protected information including Protected Health Information (PHI) and Personally Identifiable Information (PII) and reports any concerns to the Document Center Operations Manager.  Data Capture Specialist must be a team player and required to assist the entire team in meeting the Key Performance Indicators (KPI) requirements. 90% of documents are scanned, indexed and entered into the database on the same business day of receipt by Doc Center if received prior to 7:15 pm. 90% of documents are scanned, indexed and entered into the database by Noon of the following business day if received after 7:15 pm. 100% of documents are scanned within two business days of receipt by Doc Center. Competencies To perform the job successfully, an individual should demonstrate the following competencies:         Quality:  Demonstrates accuracy and thoroughness; looks for ways to improve and promote quality; applies feedback to improve performance; monitors own work to ensure quality. Must meet standards of quality that are required to meet the service levels and performance standards outlined in the SLA/KPI’s.         Quantity:  Meets productivity standards; completes work in timely manner; strives to increase productivity; works accurately and efficiently.         Dependability:  Follows instructions; responds to management direction; takes responsibility for own actions; maintains the production schedule requirements; commits to extended hours of work when necessary to reach daily production schedules and meets the daily service levels and performance standards; completes tasks on time or notifies supervisor of any potential delays or inabilities to meet the daily service levels and performance standards (SLA/KPI) requirements.           Adaptability:  Adapts to changes in the work environment; manages competing demands; changes approach or method as directed by supervisor; exhibits ability to deal with change or unexpected events. Job Requirements To perform this job successfully, an individual must be able to perform each essential duty satisfactorily, with or without accommodations.  The requirements listed below are representative of the knowledge, skill, and/or ability required.      Education/Experience Previous work experience helpful. High School Diploma or equivalent required.      Essential Functions: Knowledge, Skills, Abilities Proficient computer skills Ability to track work and document routinely Manual dexterity with proficient hand-eye coordination Excellent verbal communication skills Regular and timely attendance on the job Physical Demands and Work Environment The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.   While performing the duties of this job, the employee is frequently required to sit, talk, hear, and use hands to write, type, handle, or feel. Specific vision abilities required by this job include close vision. Specific lifting requirements include ability to lift and move trays weighing up to 20 pounds. The noise level in the work environment is usually moderate and the work environment includes proximity to many individuals like a public environment.
Contract Jun 21, 2024 Healthcare Job Title: Clinical Appeals Nurse Contract:   3-month assignment  Scheduled Weekly hours: 40 Hours.  Location: Remote (anywhere within the U.S.) - *Ohio License Is Required   The Clinical Appeals Nurse is responsible for the completion of clinical appeals and state hearings from all states. Essential Functions:   •    Responsible for the completion of clinical appeals and state hearings from all states •    Review and complete all provider clinical appeals within required timeframes. •    Review and complete member clinical appeals within required timeframes. •    Review all information necessary to prepare State Hearing packets. •    Communicate with state agencies and internal departments to prepare for State Hearings •    Attend assigned State Hearing and completed all required compliances. •    Complete required compliances for Administrative Hearing decisions •    Apply CareSource Medical Policy and Milliman guidelines when processing clinical appeals. •    Issue notification letters to providers and members. •    Issue administrative denials appropriately. •    Refer denials based on medical necessity to medical director. •    Maintain hardcopy documentation, Facets documentation and appeals database documentation at 90-95% accuracy rates. •    Conduct monthly, quarterly, and ad hoc appeals reporting. •    Collaborate with the Quality Improvement and Clinical Operations Team Lead to prepare all requests for Independent External Review •    Ensure compliance with regulatory and accrediting requirements. •    Perform any other job duties as requested.   Education and Experience: •    RN License required. •    Associate degree or equivalent years of relevant experience required. •    Managed care, appeals, and Medicaid experience preferred. •    Utilization review experience is strongly preferred. •      Competencies, Knowledge, and Skills: •    Intermediate proficiency with Microsoft Office products and Facets •    Knowledge of NCQA, URAC, OAC, and MDCH regulations •    Strong written and oral communication skills •    Ability to work independently and within a team environment. •    Critical listening and thinking skills. •    Proper grammar usage •    Time management skills •    Proper phone etiquette •    Customer Service oriented •    Decision making/problem solving skills. •    Familiarity of healthcare field •    Knowledge of Medicaid •    Flexibility •    Change resiliency.   Licensure and Certification: •    Current, unrestricted license as a Registered Nurse (RN) is required. •    MCG Certification is required or must be obtained within six (6) months of hire. 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 Jun 17, 2024 Healthcare Job Title: (RN) Well Care Coordinator Location:  Remote (South Bend, Indiana) **Must be an Indiana Resident Hours: Monday - Friday 8am-5pm Pay:  $48hr weekly pay Travel Requirement: 25% - 50% Job Summary: 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 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. Primary Responsibilities: •    Selects, manages, 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 •    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 stakeholders 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 •    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 May 30, 2024 Healthcare Job Title: (RN) Well Care Coordinator Location:  Remote (Indiana) **Must be an Indiana Resident Hours: Monday - Friday 8am-5pm Pay:  $48hr weekly pay Travel Requirement: 25% - 50% Job Summary: 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 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. Primary Responsibilities: •    Selects, manages, 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 •    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 stakeholders 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 •    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 May 23, 2024 Healthcare Job Title: (RN) Well Care Coordinator Location:  Remote (Indiana) **Must be an Indiana Resident Hours: Monday - Friday 8am-5pm Pay:  $48hr weekly pay Travel Requirement: 25% - 50% Job Summary: 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 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. Primary Responsibilities: •    Selects, manages, 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 •    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 stakeholders 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 •    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 May 7, 2024 Healthcare The Clinical Appeals Nurse is responsible for the completion of clinical appeals and state hearings from all states. Essential Functions: •    Responsible for the completion of clinical appeals and state hearings from all states •    Review and complete all provider clinical appeals within required timeframes. •    Review and complete member clinical appeals within required timeframes. •    Review all information necessary to prepare State Hearing packets. •    Communicate with state agencies and internal departments to prepare for State Hearings •    Attend assigned State Hearing and completed all required compliances. •    Complete required compliances for Administrative Hearing decisions •    Apply CareSource Medical Policy and Milliman guidelines when processing clinical appeals. •    Issue notification letters to providers and members. •    Issue administrative denials appropriately. •    Refer denials based on medical necessity to medical director. •    Maintain hardcopy documentation, Facets documentation and appeals database documentation at 90-95% accuracy rates. •    Conduct monthly, quarterly, and ad hoc appeals reporting. •    Collaborate with the Quality Improvement and Clinical Operations Team Lead to prepare all requests for Independent External Review •    Ensure compliance with regulatory and accrediting requirements. •    Perform any other job duties as requested. Education and Experience: •    RN License required. •    Associate degree or equivalent years of relevant experience required. •    Managed care, appeals, and Medicaid experience preferred. •    Utilization review experience is strongly preferred. •     Competencies, Knowledge, and Skills: •    Intermediate proficiency with Microsoft Office products and Facets •    Knowledge of NCQA, URAC, OAC, and MDCH regulations •    Strong written and oral communication skills •    Ability to work independently and within a team environment. •    Critical listening and thinking skills. •    Proper grammar usage •    Time management skills •    Proper phone etiquette •    Customer Service oriented •    Decision making/problem solving skills. •    Familiarity of healthcare field •    Knowledge of Medicaid •    Flexibility •    Change resiliency. Licensure and Certification: •    Current, unrestricted license as a Registered Nurse (RN) is required. •    MCG Certification is required or must be obtained within six (6) months of hire. Working Conditions: •    General office environment; may be required to sit or stand for extended periods of time.  
Contract Apr 11, 2024 Call Center 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, developing treatment plans, and implementing 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 timeframes. 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.     Job Type Part-time and Full-time positions available Shift and schedule On call Work Setting Remote 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.