Manage administrative intake of members Work with hospitals, clinics, facilities and the clinical team to manage requests for services from members and/or providers Process incoming and outgoing referrals, and prior authorizations, including intake, notification and census roles Assist the clinical staff with setting up documents/triage cases for Clinical Coverage Review

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, at least restrictive level of care Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact

Oversee initial inpatient admission requests for psychiatric and chemical dependency patients Make patient assessments and determine appropriate levels of care Administer benefits, review treatment plans, and coordinate transitions between various areas of care Obtain information from providers on outpatient requests for treatment Provide utilization management concurrent

Assess, plan, and implement care strategies that are individualized by patient and directed toward the most appropriate, least restrictive level of care Identify and initiate referrals for social service programs, including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact Co

Make outbound calls and receive inbound calls to assess members' current health status Identify gaps or barriers in treatment plans Provide patient education to assist with self management Make referrals to outside sources Provide a complete continuum of quality care through close communication with members via in person or on phone interaction Support members with condit

Make outbound calls and receive inbound calls to assess members' current health status Identify gaps or barriers in treatment plans Provide patient education to assist with self management Make referrals to outside sources Provide a complete continuum of quality care through close communication with members via in person or on phone interaction Support members with condit

Designs, develops, tests, documents and maintains database queries and reports Works with customers to define and document additional requirements and efficiency innovations to enrich reporting capabilities Develops systematic reporting processes and procedures to ensure timely delivery of daily, weekly, monthly, annual and ad hoc reporting to management Troubleshoots dat

Investigate medium to highly complex cases of fraud, waste and abuse Detect fraudulent activity by members, providers, employees and other parties against the Company Develop and deploy the most effective and efficient investigative strategy for each investigation Maintain accurate, current and thorough case information in the Special Investigations Unit's (SIU's) case tr

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Investigate medium to highly complex cases of fraud, waste, and abuse Detect fraudulent activity by members, providers, employees and other parties against the Company Develop and deploy the most effective and efficient investigative strategy for each investigation Maintain accurate, current and thorough case information in the Special Investigations Unit's (SIU's) case t

Facilitate member education and involvement of caregiver in the delivery of interventions Provide advocacy and support to member and family members, including caregiver support & appropriate referral to applicable / needed resources Ensure that members understand treatment options and are effectively linked to treatment resources Promote health, wellness and optimal psych

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

Plans, coordinates, and reports on health promotion and wellness education outreach activities for the health plan Executes activities designed to target gaps in care related to social risk factors and health equity while working to achieve individual and team targets Develops relationships with community organizations and providers to close gaps and allow for warm hand o

Make calls to qualified members to provide information and answer questions about health plan programs. Provide "best in class" customer service to enrollees Meet established productivity, schedule adherence, and quality standards while maintaining good attendance. Identify, qualify, and engage members into the most appropriate health and wellness programs to meet their n

Meet with business operations stakeholders to understand their requirements and objectives Develop reporting and dashboard solutions to communicate insights, measure business performance; identifies / quantifies drivers, risks and opportunities and defines solutions to mitigate risks and leverage opportunities Automate processes and reporting, including email alerts for k