Primarily answering prior authorization with inbound calls (up to 50 to 70 calls per day) from providers/members as well as research and resolve formulary and benefit issues using the appropriate reference material Process authorizations through various computer systems and use of job aid/policies/procedures ensuring the accuracy of all data and updating as necessary Have

Conduct in home assessments including an evaluation of past medical history, review of systems, medication reconciliation, vital signs, and comprehensive physical exam Perform evidence based practice screenings including point of care testing (as appropriate) Identify diagnoses to be used in care management and active medical management in the furtherance of treatment For

Conduct in home assessments including an evaluation of past medical history, review of systems, medication reconciliation, vital signs, and comprehensive physical exam Perform evidence based practice screenings including point of care testing (as appropriate) Identify diagnoses to be used in care management and active medical management in the furtherance of treatment For

Research, evaluate, identify alternative approaches, recommend, design and code efficient and effective solutions for challenging problems ranging from small to large work efforts for low to high complexity problems Develop, test, deploy and schedule complex ETL/ELT solutions to integrate multiple data asset across the organization Comply with standards and guidelines rel

Reviews medication orders and evaluates appropriateness and completeness of orders with consideration given to the special needs and behaviors of the specific age group served Obtains patient prescription and assists physician, as necessary, in formulating prescriptions and monitoring regimen Enters medication orders into the computer system and dispenses medications in a

By serving as the link between patients and the appropriate health care personnel, the SICC is responsible for ensuring efficient, smooth, and prompt transitions of care Perform Skilled Nursing Facility (SNF) assessments on patients using clinical skills and utilizing CMS criteria upon admission to SNF and periodically through the patient stays Review targets for Length o

By serving as the link between patients and the appropriate health care personnel, the SICC is responsible for ensuring efficient, smooth, and prompt transitions of care Perform Skilled Nursing Facility (SNF) assessments on patients using clinical skills and utilizing CMS criteria upon admission to SNF and periodically through the patient stays Review targets for Length o

By serving as the link between patients and the appropriate health care personnel, the SICC is responsible for ensuring efficient, smooth, and prompt transitions of care Perform Skilled Nursing Facility (SNF) assessments on patients using clinical skills and utilizing CMS criteria upon admission to SNF and periodically through the patient stays Review targets for Length o

Interview patients in a hospital setting and work effectively with hospital personnel to assist patients with obtaining maximum benefit coverage Complete applications for state and federal programs (including Health Exchange / Marketplace programs) Review medical records and take all necessary actions to expedite benefit approval Adhere to company and legal standards rega

Performing telephonic social work consultations with members promoting high quality community resources. Performing telephonic consults with member's PCP when needed. Developing a plan of care that details actions of the member and/or provider based on the social work assessment. Documenting clinical consultations, including the plan of care, into internal database. Maint

Practices in accordance with the respective state laws and regulations governing the practice of advanced practice nursing or physician assistants Establishes and maintains effective relationships with patients, care givers, and/or their legal representatives, IDT members, PCPs, other collaborating physicians/providers, and facility staff when applicable Performs an initi

Practices in accordance with the respective state laws and regulations governing the practice of advanced practice nursing or physician assistants Establishes and maintains effective relationships with patients, care givers, and/or their legal representatives, IDT members, PCPs, other collaborating physicians/providers, and facility staff when applicable Performs an initi

Practices in accordance with the respective state laws and regulations governing the practice of advanced practice nursing or physician assistants Establishes and maintains effective relationships with patients, care givers, and/or their legal representatives, IDT members, PCPs, other collaborating physicians/providers, and facility staff when applicable Performs an initi

Strategy development for direct network contracting and quality incentive program policy across the Mid Atlantic region Creating relationships, developing proposals, and driving contract execution across the region Maintaining key hospital, ancillary providers, independent practice associations (IPA's), and large physician groups relationships Leading and managing day to

Conduct in home assessments including an evaluation of past medical history, review of systems, medication reconciliation, vital signs, and comprehensive physical exam Perform evidence based practice screenings including point of care testing (as appropriate) Identify diagnoses to be used in care management and active medical management in the furtherance of treatment For