Contract Feb 14, 2025 Clerical PME is looking for a Mail Clerk to handle, sort and distribute envelopes and packages. Your goal will be to ensure our mail reaches its recipients in good condition.
Pay: $18/hour
Monday-Thursday and Saturday: 6:30 a.m. until work is complete
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 Feb 13, 2025 Healthcare Case Manager I (RN) reviewing Hospice related documentation including but not limited to physician orders, Hospice election form and certifications to coordinate care including loading pseudo authorizations into systems. This position is FULLY remote but ***MUST be a licensed CA RN residing in the state of CA. The work schedule will be M-F 8:00am-5:00pm PST.
Day to Day Responsibilities:
Roles will review Hospice documentation including physician orders, Member hospice election form, and certifications. Roles will also contact Hospice providers and members on behalf of the CA Health Plan. If documentation is accurate, the roles will load a pseudo authorization in the CA Health Plan’s system. If documentation does not support, Reviewing documentation, contacting hospices and members. Loading pseudo authorizations.
Required Education/Experience:
Hospice background strongly
Health Plan experience
CA licensed, CA based, Registered nurse.
Must have a minimum of 3 years Hospice experience
Managed Care and Case Management experience
Required License
Licensure required is a CA State License Registered Nurse – RN license
Case Manager I (RN) reviewing Hospice related documentation including but not limited to physician orders, Hospice election form and certifications to coordinate care including loading pseudo authorizations into systems. This position is FULLY remote but ***MUST be a licensed CA RN residing in the state of CA. The work schedule will be M-F 8:00am-5:00pm PST.
Day to Day Responsibilities:
Roles will review Hospice documentation including physician orders, Member hospice election form, and certifications. Roles will also contact Hospice providers and members on behalf of the CA Health Plan. If documentation is accurate, the roles will load a pseudo authorization in the CA Health Plan’s system. If documentation does not support, Reviewing documentation, contacting hospices and members. Loading pseudo authorizations.
Required Education/Experience:
Hospice background strongly
Health Plan experience
CA licensed, CA based, Registered nurse.
Must have a minimum of 3 years Hospice experience
Managed Care and Case Management experience
Required License
Licensure required is a CA State License Registered Nurse – RN license
Contract Feb 13, 2025 Healthcare Care Review Clinician I (RN) to work daily with CA hospitals, SNF’s, and other care entities to discharge CA Health Plan members safely to a reduce level of care. This position is FULLY remote, but ***MUST be a licensed RN in the state of CA. The work schedule will be M-F 8:00am-5:00pm PST.
KNOWLEDGE/SKILLS/ABILITIES
• Minimum 5 years of clinical experience as an acute care nurse in med-surg/ tele, ICU or ER setting
• Minimum of 2 years (can be part of the 5 years above) as a hospital based discharge planner for patient discharges to home, SNF, custodial care, LTAC and ARU and an in-depth understanding of what services are available in each of these settings
• Strong understanding of Medi-Cal post-acute care benefits- what is and is not a benefit
• Strong understanding of MCG inpatient criteria
• Experience with reviewing and interpreting facility contracts relating to post-acute levels of care (ie. SNF contract language)
• Must demonstrate a high level of accountability to the process of safely, effectively and efficiently transferring members that no longer meet acute care criteria to the most appropriate lower level of care
• Must demonstrate a compassionate communication style with members and providers to create seamless transitions in a member’s care
1-2 year Utilization Management experience in a HP setting
BH service background and/or MCO experience in UM
Required Education
Required Education: Nursing Degree
Required License
Licensure required is a CA State License Registered Nurse – RN license
Contract Feb 13, 2025 Healthcare Care Review Clinician I (RN) reviewing high level of care transfers. Assisting the Complex Discharge Unit on Complex Care Members. Work with transferring hospital staff and the higher level of care receiving hospital. This position is FULLY remote but ***MUST be a licensed CA RN residing in the state of CA. The work schedule will be M-F 8:00am-5:00pm PST.
Day to Day Responsibilities:
Reviewing high level of care transfers.
Assisting the Complex Discharge Unit on Complex Care Members.
Work with transferring hospital staff and the higher level of care receiving hospital.
Must Have Skills:
• 5+ years of clinical experience as an ICU or ER nurse
• Must demonstrate strong clinical skills in order to decipher the acuity of a member’s HLOC transfer needs
• Strong understanding of MCG inpatient criteria across a broad spectrum of critical care diagnosis
• Must be familiar with IPA’s, delegation, and working with providers.
• Must be able to quickly understand the health plan’s hospital network in order to ensure that PAR hospitals are utilized for HLOC transfers whenever possible
• Experience with repatriation of members back into network.
• Strong communication skills and ability to interact effectively with hospital nurses, attending physicians, hospital administrative staff, and medical directors responsible for transferring and receiving members
• Must demonstrate a high level of accountability to the process of safely, effectively and efficiently transferring members to higher level of care facilities
Required Education/Experience
Minimum 5 years within the last 3 years in the ED preferred. CA Managed Care experience preferred.
Required License
Licensure required is a CA State License Registered Nurse – RN license
Contract Feb 13, 2025 Healthcare Care Review Clinician I (RN) to work daily with CA hospitals, SNF’s, and other care entities to discharge CA Health Plan members safely to a reduce level of care. This position is FULLY remote but will require minimal travel within CA (i.e. Laboratory equipment validation). ***MUST be a licensed RN in the state of CA. The work schedule will be M-F 8:00am-5:00pm PST.
KNOWLEDGE/SKILLS/ABILITIES
Work with Corporate Special Investigations Unit (SIU) to perform work on behalf of the CA Health Plan.
Review CLIA certification documentation from laboratories, contacting laboratories and California members.
Review fraud, waste, and abuse inquiries on behalf of the CA Health Plan.
Must Have Skills:
CA Registered Nurse with strong background in Fraud Waste and Abuse
Hospice experience preferred
Case Management experience preferred
Required Education
Nursing Degree
Required License
Licensure required is a CA State License Registered Nurse – RN license
Direct Hire Feb 13, 2025 Other Area(s) Job Title: Contract Specialist
Location: Indianapolis, IN (Hybrid – 3 Days Onsite, 2 Days Remote)
Employment Type: Full-Time
About Us
Professional Management Enterprises Inc. (PME) is a leading small business specializing in staffing, consulting, and contract management solutions across SLED (State, Local, and Education) and Federal markets. As we continue to expand, we are seeking a Contract Specialist with five years or less of experience to support our growing portfolio of government contracts.
Overview: The SLED (State, Local, and Education) Market Contract Specialist plays a pivotal role in managing contracts and agreements within the SLED sector. This role requires meticulous attention to detail, strong negotiation skills, and comprehensive knowledge of procurement regulations within the public sector. The primary objective is to facilitate the contract lifecycle, ensuring compliance, mitigating risks, and optimizing terms to achieve favorable outcomes for all parties involved.
Responsibilities:
Contract Management: Oversee the entire contract lifecycle, including drafting, negotiation, execution, and renewal, ensuring adherence to company policies and regulatory requirements.
Bid and Proposal Development: Collaborate with sales and account management teams to develop competitive bids and proposals tailored to the unique needs and regulations of the SLED market.
Compliance Assurance: Ensure all contracts and agreements comply with relevant laws, regulations, and procurement policies governing the SLED sector, including but not limited to FAR, DFARS, and state-specific regulations.
Negotiation: Conduct negotiations with SLED agencies, vendors, and partners to optimize contract terms, pricing, and service level agreements while maintaining a positive relationship with stakeholders.
Risk Management: Identify and mitigate potential contractual risks, such as legal, financial, and reputational risks, through thorough analysis and proactive measures.
Relationship Building: Cultivate and maintain strong relationships with SLED agencies, vendors, partners, and internal stakeholders to facilitate smooth contract processes and foster collaboration.
Documentation and Reporting: Maintain accurate records of all contracts, amendments, and related documents, and generate regular reports on contract status, performance, and compliance.
Market Analysis: Stay informed about market trends, regulatory changes, and competitive landscapes within the SLED sector to provide strategic insights and support decision-making processes.
Requirements:
Bachelor’s degree in Business Administration, Finance, Legal Studies, or related field. Advanced degree or certification in Contract Management or Procurement is a plus.
Proven experience (5+ years) in contract management, procurement, or related roles, preferably within the SLED market or public sector.
In-depth knowledge of procurement regulations and procedures governing the SLED sector, including familiarity with FAR, DFARS, and state-specific regulations.
Strong negotiation skills with the ability to effectively communicate and persuade stakeholders to reach mutually beneficial agreements.
Excellent organizational skills and attention to detail, with the ability to manage multiple contracts and deadlines simultaneously.
Proficiency in contract management software and Microsoft Office suite.
Analytical mindset with the ability to identify and mitigate risks, solve problems, and make data-driven decisions.
Exceptional interpersonal skills and the ability to build and maintain relationships with diverse stakeholders.
Preferred Qualifications:
Experience working with SLED agencies or educational institutions.
Familiarity with government contracting processes and compliance requirements.
Certification in Contract Management (e.g., CPCM, CFCM, CCCM) or related field.
Knowledge of specific industry standards and best practices relevant to the SLED market (e.g., IT, healthcare, education).
Experience with proposal development and responding to RFPs (Request for Proposals) or RFQs (Request for Quotes).
This job description outlines the essential duties and qualifications required for the role of a SLED Market Contract Specialist. The position demands a combination of contract management expertise, regulatory knowledge, and interpersonal skills to navigate the complexities of the public sector procurement landscape effectively.
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 12, 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.
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
Driver’s License required
High School Diploma/GED required
Contract To Hire Feb 12, 2025 Accounting Duties:
Examine Admission and Discharge Episode of Care Records
Ensure Adequate Clinical Documentation
Verify Level of Care
Ensure Compliance with MLA Billing Procedures and Standards
Prepare, Code and File Claims
Track Claims Status, Approvals
Ensure EOB Accuracy
Ensure Accurate Payment Posting
Ensure Accurate Data Entry
Process Denials and Appeals
Perform such other and further duties as assigned by the MLA Revenue Cycle Director
Qualifications:
· Proven working experience as a Medical Accounts Receivable Specialist or similar role.
· TRICARE Health Plan billing experience (Must have)
· Knowledge of billing procedures and collection techniques
· Familiarity with medical terminology and healthcare regulations.
· Proficiency with MS Office and databases.
· Excellent communication and data entry skills.
· Attention to detail and problem-solving ability.
· Understanding of medical coding and billing software.
· High school diploma; degree in Business Administration or related field is a plus.
Contract Feb 12, 2025 Healthcare The Managed Care Contract Coordinator is responsible for ensuring contracts are accurate and compliant with regulatory guidelines, by reviewing all contact details, and ensuring approvals are received for non-standard agreements.
Fully Remote / $16/hour
40 hours week / 5-month contract
Essential Functions:
Ensure contracts are accurate and compliant with regulatory guidelines, by reviewing all contact details, ensure approvals are received for non-standard agreements
Create basic contract documents for new providers, obtain any missing documentation to complete a provider packet
Coordinate efforts with internal departments and providers offices to complete and obtain missing documentation
Perform auditing of the contract, attachments and other provider documents for accuracy and completeness
Promptly and accurately notate internal systems of all data maintenance requests
Prepare documentation when applicable to facilitate data maintenance updates, ensuring all documentation is compliant with state, federal and all applicable governing entities
Proficient in all systems needed to create, research and process maintenance
Assure compliance with corporate policies and procedures.
Assist with Recruitment efforts by placing outbound calls to leads and/or preparing/tracking and following up on mass mail projects.
Field incoming calls from providers regarding contract or amendment status
Assist Contractors with preparing for Orientations by ordering packets, supplies and if necessary, assisting on-site with sign-in etc.
Assure the confidentiality of provider information and ensure all provider files are securely stored at close of business each day.
Knowledge of all regulatory requirements and internal processes to ensure that all maintenance and contractual documents are managed to expectations
Meet departmental productivity and quality standards
Perform any other job duties as requested
Education and Experience:
High School Diploma or General Equivalency Diploma (GED) is required
Associate of business administration degree or related field is preferred
Minimum of one (1) year of experience in a managed care or healthcare organization or contract development and review is required
Prior experience with provider documents and provider data entry is highly preferred
Competencies, Knowledge, and Skills:
Intermediate computer skills including Microsoft Word, Excel, and Outlook
Communication skills
Ability to work independently and within a team environment
Attention to detail
Familiarity of the healthcare field
Knowledge of Medicaid
Critical listening and thinking skills
Technical writing skills
Time management skills
Customer service orientated
Decision making/problem solving skills
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 12, 2025 Information Technology Job Title: Integration Project Manager
8 month assignment
Remote/WFH position
The Integration Project Coordinator is responsible for managing individual low to medium complexity workstreams within the context of integration or assisting with the management of medium to high complexity workstreams.
Essential Functions:
Responsible for successful delivery of project
Schedule and facilitate project meetings including weekly status meetings and stakeholder meetings
Capture and report on meeting notes, decisions, and action items
Lead stakeholders in the refinement of the project charter
Lead stakeholders in the current state documentation process
Lead stakeholders in the future state recommendation process
Ensure project milestone deliverables are completed and approved at every stage of the project lifecycle
Assist with the continuous improvement of project management best practices, processes, and tools
Responsible for ensuring project closure activities are completed
Develop and maintain project schedule
Collaborate with IT point of contact on the identification and assignment of IT resources
Develop and maintain project budget if applicable
Capture and consolidate IT and business estimates for project
Assess, manage, and control project scope, schedule, and budget change impacts
Escalate issues to Business Owner, Program Manager, and IMO Leadership as applicable
Maintain project stakeholder matrix
Drive cross-functional communication between impacted business and IT areas
Lead in preparation for Portfolio Governance meetings
Work with Talent Development and Communications to develop project communication and training plans
Accurately track and report project status against plan to stakeholders at all levels
Track, compile and report project metrics and budget
Advocate for and adhere to IMO standards, tools and processes
Implement mitigation strategies, contingency plans, and communicate/escalate to stakeholders
Maintain RAID for project items
Identify, log, assign and manage risks and issues
Maintain project SharePoint site and project document repository
Produce detailed reports, business decision documents, meeting minutes, and notification on assigned projects
Perform any other job duties as requested
Education and Experience:
Bachelor’s Degree in Project Management, Business, Computer Science or related field or equivalent years of relevant work experience is required
Minimum of two (2) years of project management experience is preferred
Familiarity of healthcare payer industry and knowledge of Medicaid and Medicare is preferred
Competencies, Knowledge and Skills:
Experience with Microsoft Office tools, including Project, Word, PowerPoint, Excel, Visio, Teams, Outlook, etc.
Experience working in project management software is preferred
Demonstrates analysis and reporting skills
Excellent decision making/problem solving skills
Demonstrates interpersonal and relationship building skills
Demonstrates critical listening and thinking skills
Ability to effectively interact with all levels of the organization
Excellent written and verbal communication skills
Customer service oriented
Ability to proactively, effectively and efficiently lead a project team of up to 15 core members and multiple external vendors
Experience managing a project of up to $2M in budget
Ability to prioritize work and team assignments to deliver projects on time, on budget, and meeting stakeholders expectations
Demonstrates a sense of urgency
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 12, 2025 Healthcare Job Title: Nurse Medical Manager I
Hours: 40 hours week (weekly pay)
**Remote/WFH**
Nurse Medical Manager I to be responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. ***Must reside in the state of MO and within 50 miles of the St Louis Pulse Point. ***Must have an unrestricted MO RN license. This position is fully remote and 40hrs per week, 8am-5pm M-F.
JOB SUMMARY
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.
Works with medical directors in interpreting appropriateness of care and accurate claims payment.
May also manage appeals for services denied.
Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
Ensures member access to necessary medical and quality healthcare in a cost-effective setting according to contract.
Consult clinical reviewers and/or medical directors to ensure appropriate medical, 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.
EDUCATION/REQUIREMENTS
Requires current active unrestricted RN license for the state of MO.
Utilization management experience preferred, using MCG criteria guidelines.
2 years acute care clinical experience required.
Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Excellent attendance, comfortable in a virtual environment and strong computer skills
Contract Feb 11, 2025 Healthcare Job Title: Care Coordinator | Case Manager
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 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 29, 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 Jan 27, 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.
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
Driver’s License required
High School Diploma/GED required
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.
Contract Jan 6, 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.