• US National

Create, update, and maintain internal procedural content. Review and edit documents for accuracy and consistency. Enter content into templates and knowledge management system. Monitor request queues and incorporate updates into knowledge articles.

• US National

Responsible for managing department systems changes, testing, and implementation. Evaluates processes, leads initiatives for IT integration, and increases providers' adoption of the Plan's portal. Responsible for UM reporting function.

• US National

Develop and maintain operational processes and procedures for Utilization Management. Monitor and report on performance metrics. Integrate UM functions across the organization. Lead and manage a team of non-clinical staff.

• US National

Establish and manage end-to-end processes for Encounters data management. Oversee projects, create issue resolution process, establish quality metrics, communicate priorities, and propose mitigation activities. Monitor guidelines and collaborate with..

• US National

Strategically network to generate leads and build relationships, ensure compliance with enrollment and marketing policies, analyze performance data, and oversee regional sales team's participation in community events.

• US National

Develop and maintain relationships with providers, community partners, and potential prospects. Prospect and enroll potential members. Implement outreach strategy to meet membership goals. Assure compliance with enrollment and marketing regulations.

• US National

Lead efforts to obtain and maintain accreditation from oversight bodies. Collaborate with internal and external partners to implement projects and initiatives. Act as key contact for accreditation agencies and provide expertise to internal staff.

• MA, NH

Provide telephonic care management services for members receiving behavioral health services. Develop and implement care and treatment plans, conduct assessments and screenings, outreach for medication monitoring, and document clinical assessments.

• US National

Manages portfolio of member items and corresponding budget, develops annual budget, manages member reimbursement decisions and payments, manages vendor selection and relationships, manages Marketing Operations team, ensures corporate identity and bra..

• US National

Create engaging and effective training materials for the Operations Department. Develop project plans, implement monitoring, and conduct content reviews. Collaborate with stakeholders and assist in developing internal tools and resources.

• US National

Assess member needs and collect data to assist in better health management. Educate members on obtaining resources and provide education classes. Assist members in completing applications for community resources.

• US National

Develop, maintain, and manage behavioral health plan fee schedules and code pricing. Monitor multi-state regulations and implement necessary changes. Collaborate with various departments to support behavioral health pricing/fee schedule.

• US National

Responsible for accurate and timely implementations of pharmacy benefits and operations configurations. Provides project management support for all pharmacy services initiatives across all lines of business.

• US National

Develop and facilitate training programs for Claims, Call Center, and Enrollment teams. Monitor trainee progress, maintain accurate records and evaluate training effectiveness. Stay current on learning trends and promote company values.

• US National

Lead accreditation and clinical delegation teams to maintain NCQA Health Plan and Health Equity Accreditation. Ensure compliance with NCQA standards, manage workload, oversee surveys, and develop strategies to ensure ongoing readiness for all accredi..

• US National

Develop and maintain payment policies to align with the organization's Behavioral Health strategy. Collaborate with cross-functional business and IT partners to implement recommended policy changes. Research and propose opportunities for performance ..

• US National

Manages a panel of high-risk, medically complex members. Completes timely assessments and develops individual plans of care. Utilizes evidence-based guidelines to improve clinical outcomes and facilitate access to community resources.

• US National

Lead quality improvement and accreditation activities, develop and oversee strategies, policies, and processes, and supervise staff. Ensure compliance with contractual and regulatory quality requirements and measures.

• US National

Analyze medical management systems, evaluate activities and processes, and develop UM program. Coordinate data management activities, create and maintain documentation, and identify opportunities for improvement. Manage projects and facilitate intra...

• US National

Screen inpatient admissions requests, prioritize and process incoming requests, authorize specified inpatient admissions requests, and answer provider calls. Requires 2 years of office experience and an associate's degree in healthcare or a related field.

• US National

Creates and submits monthly, quarterly, and annual regulatory reporting. Develops business requirements and works with IT to obtain data and create reports. Maintains the accuracy and integrity of data universe tables.

• US National

Review and implement federal and state guidance, lead audit preparations and responses, maintain accurate documentation, develop internal controls, support business areas in applying regulations, oversee audit activities across various programs and a..

• US National

Lead a team to attain and maintain NCQA Health Plan Accreditation and NCQA Health Equity Accreditation, ensure compliance with NCQA standards, manage team workload, and provide updates on accreditation progress.