Utilization Management jobs near me - 550 jobs

Why Work Here? Be Valued! As a public service agency, we know our greatest assets are the people behind the service. We recognize the value of our employees through competitive pay and an amazing benefit package for staff and their family. Franklin County Public Health is proud to be an equal opportunity employer committed to hiring a diverse and inclusive workforce. The FCPH value statement says it all: We serve our communities, our organization, and each other with Integrity, Accountability, Excellence and Respect. Franklin County Public Health provides: * Schedules to support a work/life balance. * Robust benefits including medical, dental, vision, an employee assistance program and a flexible spending account. * Life insurance, short- and long-term disability options are also offered. * Vacation time, personal time, sick time, and paid holidays. * And much more! NOW HIRING: Behavioral Health & Addiction Services Harm Reduction Supervisor The Behavioral Health & Addiction Services (BHAS), Harm Reduction Supervisor position will provide supervision in the development, implementation, and coordination of evidence-based, or informed injury prevention, harm reduction non-clinical addiction services programs, including policy, system and environmental change strategies, processes, and interventions to support community-based substance free, healthy living. The Supervisor will oversee the development, coordination and facilitation of the agency's community-based harm reduction and outreach programs and initiatives to address mental/behavioral health, substance use disorders, disparities, and social determinants of health. This position assists with writing, editing, and collecting documentation to assure full compliance with all grant deliverables and deliverable outcomes and assists with identifying and approving grant expenditures. Duties include: * Provides administrative support and supervision to staff for monitoring performance, provides training to teach new skills and coaches to improve performance. * Provides supervision, guidance and oversight, for the BHAS harm reduction, harm reduction vending machines, community outreach, mobile outreach van, mobile syringe service, naloxone, and peer support programs. * Utilizes management tools in the development and monitoring of program activities, including partner outreach, program service planning and delivery, to community-based organizations. * Works toward implementing the agency one-goal of equity, strategic plan, community health assessment, and community health improvement plan. * Offers guidance and support in identifying resources that support addressing social determinants of health; Identifying barriers to care and services in areas such as but not limited to; education, transportation, housing and understanding procedures and language barriers. * Determines resources required for projects and the most feasible and cost-effective methods to gather data; develops work plans; assigns priorities and time limits. * Conducts quality improvement reviews; develops and implements action plans to improve effectiveness and efficiency of staff. * Assists in the planning and implementation of operational procedures and provides program management with continuous feedback about operations. * Attends local events, meetings and trainings to stay abreast of the most innovative approaches and disseminate related information within the community and agency. * Manages section budget and continuously researches grant or other opportunities to increase section revenue. •Responsible for the expansion and development of a comprehensive Harm Reduction Mobile Unit, works collaboratively across divisions to manage use and maintenance of the mobile unit. * Other related duties as assigned. Requirements: * Master's degree with a focus in injury prevention, social work, social services, behavioral health, addiction services, public health, or public administration. * LISW, LICDC-CS, MSW or LSW required. * 3 years' work experience in the field of addiction services * 2 years' experience in social services, policy management, public health, behavioral health substance use, or social work * Ohio Driver's License. * Experience in grants management, federal grants management experience preferred. Hiring Wage Range: $35.04/hour - $42.05/hour. This is an exempt position. Interested applicants should apply at ***************************************** with: * Resume * Cover letter * Completed FCPH application (located: ****************************** Deadline for Applying: Internal applicants (11/11/2025); External applicants (Until filled) No phone calls please. Franklin County Public Health is proud to be an Equal Employment Opportunity employer. We do not discriminate based upon race, religion, color, national origin, gender, sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Learn more at *************** FCPH is committed to providing a healthy work environment for all employees, and all employees agree to be non-tobacco users as a condition of employment (e.g., cigarettes, cigars, smokeless tobacco, vapor, etc.). All applicants offered positions with FCPH must submit to and pass a drug and alcohol screen before beginning work. Applicants with disabilities may contact Victoria Bradley, HR Generalist at ************************************** or ************ to request and arrange for accommodations. The above statements are intended to describe the general nature and level of work being performed by people assigned to this position. They are not intended to be interpreted as an exhaustive list of all responsibilities, duties, and skills required of personnel in this position.

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together. The Sr. Manager, Network Management is responsible for contracting with all provider types and successful provider network performance related to key financial, operational, and member satisfaction performance indicators in a multi-market territory. Works closely with Network Management and other departments to enhance the contracted provider experience consistent with company's mission statement and values. General Duties/Responsibilities (May include but are not limited to): Collaborate with Network Management leadership in the development and execution of the contracting strategy. Recruit providers to eliminate network deficiencies within a specific region. Negotiate / re-negotiate and finalize all contracts which may be primary care, specialist, ancillary, hospital, group/IPA as well as ensure the accuracy of administration of these agreements. Manage staff; lead, mentor and coach staff effectively Assure the day-to-day operations of the provider network are consistent with standards/ expectations and develops provider education materials as needed to support adherence with company requirements. Develop agendas and lead Joint Operations Meetings to drive results, including oversight of New Provider Orientations and new Contract Orientations. Meetings will focus on addressing performance improvement metrics, resolving operational issues, including but not limited to utilization management, financial, enrollment, member appeals and grievances, provider termination/panel closures, continuity of care, and marketing activities. Responsible for the execution of regional work-plans, monitoring performance metrics, updating status, and communicating progress both internally and externally to ensure results. Responsible for timely and professional interaction with internal and external customers. Ensure accurate and timely data reporting requirements are being met for designated regions, including but not limited to provider network contacts, eligibility and capitation reports, risk sharing, claims timeliness, pharmacy utilization, bed day utilization, encounter data and audit compliance. Develop goals and objectives that align with Network Management leadership's performance metrics to ensure department KPIs are met, as well as the organization's vision for future growth and network development. Utilize contracting knowledge for effective problem resolution and compliance. Responsible for timely and professional interaction in response to grievances. Research, analyze and resolve complex problems dealing with hospital shared risk pool, claims, appeals, and eligibility issues within the appropriate limits. Create and implement policies and procedures for the department. Interpret company policies and procedures. Represents the department in interdepartmental meetings and selected committees. Other projects and responsibilities as assigned Supervisory Responsibilities: Oversees assigned staff. Responsibilities include recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees. Will also oversee third-party vendors and/or student workers as appropriate. Minimum Requirements: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Minimum Experience: Minimum 5-7 years' experience with an HMO, managed care provider organization (IPA, Medical Group or institutional provider) or insurance company with at least 5 years' specific experience in managed care contracting and knowledge or Medicare Advantage regulatory guidelines. Previous supervisory experience; demonstrated abilities to manage staff Education/Licensure: Bachelor's Degree or equivalent experience required Other: Proficient in MS Office, including strong Word and Excel proficiency. Detail oriented. Language Skills: Ability to read and interpret documents such as contracts, safety rules, operating and maintenance instructions and procedure manuals. Ability to interpret government regulations a must. Ability to write routine reports and correspondence. Ability to speak effectively before groups of providers or employees of internal/external organization. Mathematical Skills: Ability to calculate figures and amounts such as fee schedules, per diem rates, discounts, interest, commissions, proportions, and percentages. Ability to apply concepts of algebra, geometry and statistics. Reasoning Skills: Strong analytic and problem-solving skills required, including ability to synthesize, interpret and apply detailed and complex information. Office Hours: Monday-Friday, 8am to 5pm. Extended work hours, as needed. Maintain reliable means of transportation. If driving, must have a valid driver's license and automobile insurance. Drives approximately 20-40% of the time to provider sites. Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Essential Physical Functions: The physical demands 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 regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus. Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran. If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact ****************** . Pay Range: $91,651.00 - $137,477.00 Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc. Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation. *DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at ******************************* If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health's talent acquisition team, please email ******************.

JOB TITLE: Residential Facility Assistant Administrator FLSA: 1.0 FTE, Exempt (Expectation to work 40 hours a week) SUPERVISOR: Facility Administrator PAY GRADE: B9 ($56,700 - $82,700 annually, depending on experience) **STAR is a BRAND NEW 24-hour sub-acute/Psychiatric Residential Treatment Facility (PRTF) offering services for up to thirteen individuals, ages 12 and below. Community Counseling Solutions provides a team-based Servant Leadership environment! Our mission is to provide dynamic, progressive, and diverse supports to improve the well-being of our communities and we're looking for motivated employees to help us continue our vision! Location Information: Boardman is located in Eastern Oregon with year-round recreation based near the Blue Mountains. Boardman offers a unique blend of small-town charm and big opportunities. With its stunning views of the Columbia River, abundant outdoor recreation, and a growing economy driven by agriculture, energy, and technology, Boardman is a place where work-life balance truly thrives. Whether you're drawn to the peaceful pace of rural living or excited by the chance to be part of a dynamic and supportive community, Boardman provides the perfect setting to grow your career while enjoying the natural beauty and warmth of a close-knit town. Apply Directly at ********************************** CCS has a benefit package including, but not limited to: Health, dental and vision insurance 6% initial 401K match Potential for tuition reimbursement Paid vacation tiers ranging from accrual of 1 day to 4 days per month (Annual rollover cap of 220 hours, additional hours can be paid out at 50% at the end of the fiscal year) 9 Paid holidays, Community service day Floating holiday & 2 mental health days provided after 1 year introduction Workplace Flexibility schedule options available (work from home hours vary by position & schedule) Exempt employees receive additional admin leave & work from home hours Relocation Benefit of up to $4,000 if moving over 100 miles, $ depending on distance. This is available to be included w/ job offer Student loan forgiveness (NHSC & Public Service) Paid licensure supervision. Employee Assistance, Wellness Benefits, Dependent Care & Long-Term Disability Insurance DESCRIPTION This position provides assistance to the Facility Administrator for daily managerial oversight of the operations of a Residential Treatment Facility. The facility provides a secure setting to assist with the stabilizing and/or recovery of youth who have a severe and persistent mental illness. This position is split, half time as assistant administrator and half time working as a mental health specialist/QMHA. Provides oversight of the daily operations of the children's sub-acute/Psychiatric Residential Treatment Facility (PRTF) for up to thirteen individuals, ages 12 and below. The Administrator ensures that high quality and safe treatment is provided and oversees the quality of training and supervision of the Assistant Administrator, Clinicians, Residential Associates, and other employees who provide the 24-hour sub-acute/PRTF services to the residents. SUPERVISION Supervision Received This position is supervised by the Facility Administrator of Specialized Treatment and Resiliency Center, STAR. The Facility Administrator will provide both administrative supervision and clinical supervision. Supervision Exercised This position directly supervises all assigned staff at the facility. RESPONSIBILITIES Assist the administrator in meeting and maintaining all standards and procedures for the provision of care, clinical and rehabilitation services for youth using an array of milieu based and clinical methods to stabilize and treat adverse behaviors in the least restrictive manner possible. Including but not limited to: Monitor the daily activities of the secure residential treatment facility. Supervise, train and evaluate staff, provide on-going training and evaluate staff performance. Responsible for scheduling staff to ensure adequate client supervision and support. Review and verify timesheets. Is accessible by telephone or pager for emergency purposes and provides responsible support, documentation and follow-up in a timely manner if needed. Develops and participates in an on call schedule for such purposes. Is knowledgeable about personnel policies, AFC, OAR and applicable rules and standards of other pertinent regulatory agencies, such as OSHA. Maintains up-to-date personnel, client and program records including the accounting of client and facility funds, training and activity records, medical and health supports. Assures that house supplies (program & client) are purchased in a timely manner, maintained in adequate supply, and stored in a safe and sanitary manner Assure that evacuation drills are conducted according to AR requirements. Maintains professional confidentiality of personnel, clients and the program(s). Coordinates and participates in the development of each resident's Individualized Support Plan. Follow the grievance process for all complaints submitted and work diligently to resolve the complaints. Ensure that the agency is meeting or exceeding all requirements for the relevant OAR's. Work with contracted prescribers to put together scheduled and ensure that the service delivery is well coordinated for prescribers and the customers they see. Consult with prescribers to coordinate medical treatment. Ensure that all paperwork is completed by all staff and is timely and professional and provide supervision when that goal is not being met. Report all cases of abuse and neglect to correct agency. Provide utilization management for adults needing higher levels of care. Schedule and participate in meetings with other agencies to ensure continuity of service delivery and ensure that CCS is highly regarded by community partners. Participate in all internal administrative meetings. Hold regular staff meetings. Communicate with members of the public to coordinate work programs, inform the public about our services, and speak with groups about our services and/or specific areas of mental health services. Transport residents as needed. Receive and promote all training as needed. Develop, implement and follow policies and procedures relevant to the operation of the facility that meet state requirements as well as any other requirements of other licensing, certifying or insuring organizations. Other duties as assigned. Requirements EDUCATION AND/OR EXPERIENCE Individual must have two years of training, coursework or experience in psychology, counseling, or other human services related field Individual must have a high school diploma or equivalent In addition, it is preferred that this individual will have 3 years experience working in a residential setting that provides services to individuals with a mental illness. OTHER SKILLS AND ABILITIES Establish and maintain an accessible and up-to-date filing system of client, personnel and program information. Read and research related technical materials and to write clear plans and proposals. Establish effective working relationships with community resource agencies, co-workers and the general public. Act independently and work effectively with minimal supervision. Problem solves complex issues by developing alternatives and solutions. Organize and establish priorities. Negotiate conflicts and resolve problems. Interact and relate to clients, staff, administrators and others with professionalism, respect and dignity. Work with clients experiencing crisis situations. The position requires the handling of highly confidential information. Must adhere to rules and laws pertaining to client confidentiality. Must posses, or have the ability to possess functional knowledge of business English and medical terminology. Must have good spelling and basic mathematical skills. Must have the ability to learn assigned tasks readily and to adhere to general office procedures. Good organizational and time management skills are essential Must possess the ability to represent the interest of the customer and the agency in a favorable light in the community Must have the ability to work well with teams and other groups of individuals. Must have in depth knowledge of standard office equipment. Must be able to communicate effectively in both written and oral formats. Must have the ability to present and exchange information internally across teams and co-workers, and externally with customers and the public. PHYSICAL DEMANDS While performing the essential duties of this job, the employee is regularly required to use office automation including computer and phone systems that require find manipulation, grasping, typing and reaching. The employee is also regularly required to sit; talk and hear; use hands and fingers and handle or feel. The employee is occasionally required to stand; walk; reach with hands and arms; stoop; kneel and/or squat when adjusting equipment or retrieving supplies. The employee may occasionally lift and/or move up to 30 pounds. Specific vision abilities required by this job include close vision, peripheral vision, distance vision and the ability to adjust focus. Residential Facility Assistant Admin Page 3 of 5 Employee may be required to work weekend shifts. Reasonable accommodations may be made to enable persons with disabilities to perform the essential functions of this position. Must be willing to work a flexible work schedule depending on community and resident needs. WORK ENVIRONMENT Work is performed in an inpatient services environment as well as within the community. The noise level is usually moderate, but periodically staff may be exposed to loud noise such as raised voice levels and alarms. The noise level in the office environment is usually moderate, but occasionally one may be exposed to loud noises. Occasional out of area travel and overnight stays will be required for attendance at meetings and/trainings. However, the employee may be required to work in the community. Handicap access may not be available at all places where this position must go. There are some situations where this position may be required to respond to environments where a client is in crisis. The environments in these situations are difficult to predict and may be in uneven terrain. This position exposes the employee to the everyday risks or discomforts which require normal safety precautions typical of such places as an office or home environment. PERSONAL AUTO INSURANCE Must hold a valid driver's license as well as personal auto insurance for privately owned Vehicles utilized for CCS business such as client service purposes, travel between business offices and the community, to attend required meetings and trainings. Must show proof of $300,000 or more liability coverage for bodily injury and $100,000 or more in property damage and maintain said level of coverage for the duration of employment at CCS. The employee's insurance is primary with CCS insurance being secondary. CCS reserves the right to deny any employee the use of a vehicle owned by CCS. CRIMINAL BACKGROUND CHECKS Must pass all criminal history check requirements as required by ORS 181.536-181.537 and in accordance with OAR 410-007-0200 through 410-007-0380. In addition to a pre-employment background check, each employee, volunteer and contractor shall be checked on a monthly basis against the OIG and GSA exclusion lists, as well as other federal and state agency lists. If it is discovered that an employee, volunteer or contractor is excluded or sanctioned it will be the cause for immediate termination of employment, volunteering, or the termination of the contract. Community Counseling Solutions IS AN EQUAL OPPORTUNITY EMPLOYER MEMBER OF NATIONAL HEALTH SERVICES CORPORATION Salary Description $56,700-$82,700 annually, depending on experience

Join American Structurepoint and become part of a team that goes the extra mile for our clients and communities. We live by our values - respect, staff development, results and family. Our team is encouraged to explore new ideas and turn our clients' dreams into reality. With exceptional benefits, training, and mentorship, we pave the way for a rewarding career. Ready for more than just a job? Explore opportunities with us and help improve the quality of life in the communities we serve. We encourage our experts to try new things and explore new ideas that turn our client's dreams into reality, even if those ideas are unconventional. We invest in our people by offering excellent benefits and training, development, and mentorship opportunities that lead to a rewarding career path. If you are ready for more than a career, we invite you to explore opportunities to join our team and help us improve the quality of life for the communities we serve. Group: Utility Infrastructure Position: Technical Director Location: Indianapolis, IN / Ft. Wayne, IN / Columbus, OH / Cleveland, OH / Cincinnati, OH / Chicago, IL - Relocation Available. Position Summary The Technical Director serves as an internal resource to increase the technical capabilities of the entire Utility Infrastructure Group. A Technical Director works under the direction of the Utility Infrastructure leadership and serves as a technical expert representing American Structurepoint to existing and potential clients. Responsibilities of this role are divided among providing technical direction on complex projects; knowledge sharing/mentoring of less-experienced staff; quality management; development/maintenance of technical standards; and pursuit of new project opportunities. Specific Duties A Technical Director must be proficient in all the engineering and management tasks of Engineers and Project Managers and draw on their broad engineering experience and areas of expertise to contribute to the Utility Infrastructure Group. Responsibilities Technical Leadership Provide technical guidance to utility infrastructure staff in the areas of regulations, drinking water, wastewater, stormwater, construction, funding, and/or utility management. Provide technical guidance to utility infrastructure staff in the areas of regulatory compliance, funding sources, alternative project delivery, construction, utility management, drinking water (source of supply, treatment, residuals handling, pumping, distribution, storage), wastewater (collection, CSOs, lift stations, treatment, biosolids), and stormwater management (drainage, green infrastructure) Provide technical direction on high-profile, large, and/or complex projects Solve technical problems Write technical papers and conduct presentations at conferences maintaining a reputation in the industry as a subject matter expert Communicate complex ideas to a diverse audience Participate in local and/or national industry, professional, and community organizations Quality Assurance Lead quality management process Provide quality review of projects at milestones Lead improvement of standard design documents and tools Staff Development Lead knowledge sharing internally by organizing continuing education programs Develop technical skills of Engineers and Project Managers Develop Project Managers to prepare proposals, establish fees, create/maintain client relationships Participate in employee performance reviews Lead collegiate environmental engineering outreach program Participate in employee hiring process Utility Infrastructure Vision Define and pursue strategic practice areas and capabilities to position the team for maximum potential performance and profit in the marketplace Setting and following business development plans setting the direction of the Utility Infrastructure group within the company Client Management Maintain positive relationships with existing clients, focused on developing profitable repeat work Provide technical support for our sales force Serve as Principal-in-Charge for selected clients Marketing and Sales Look for opportunities to sell new projects to existing and new clients Identify and pursue strategic markets Accompany business development staff to establish new client relationships and provide technical support Develop the proposal for project work, scope of work, services, subconsultant agreements and fees (or work with appropriate staff to get this accomplished) Understand past project performance, historical, and industry data to determine project costs and to develop pricing for maximum profitability in the market Performance Measures: The primary measurement of success for this position is the overall growth of volume and profitability of our Utility Infrastructure business unit. Other measurements are as follows: Utilization rate goal of 60% Technical accuracy and completeness of projects as measured by client satisfaction and construction Training and mentoring efforts Growth of Utility Infrastructure business in strategic markets Active participation in project pursuits Active participation in professional organizations Number of client relationships established and maintained Meeting effectiveness as measured by presenting information, solving problems, making decisions Keeps leadership informed of project status Maintains professional relationship with staff and elicits cooperation Keeps up with codes, design guidelines, policy manuals and their application Explores alternative and innovative approaches to problems before deciding on a course of action Performs effectively under pressure Qualifications Education: Bachelor's Degree (Master's or PhD preferred) in Environmental Engineering or Equivalent Experience: Registered engineer with 15 or more years diversified Utility Infrastructure engineering/management experience Broad technical knowledge of the utility infrastructure engineering (drinking water, wastewater, stormwater) and construction industry, with specific areas of technical expertise Experience in sales and marketing of services, as well as a track record of building client relationships Demonstrated network of existing clients and ability to pursue new client relationships Proven leadership ability, as well as excellent written and verbal communication skills Certification: Professional Engineering License in at least one state, with ability to obtain Indiana licensure within six months of employment; Board Certified in Environmental Engineering (BCEE), preferred

The MyCare Ohio Plan program is to deliver high‐quality, trauma informed, culturally competent, person‐centered coordination for all members that addresses physical health, behavioral health, long term services and supports, and psychosocial needs. Medical Management Specialist I Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. This position will be based at any Pulse Point available in Ohio, US. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Schedule: This position will work an 8-hour from shift 8:00 am - 5:00 pm (EDT) Monday to Friday. Additional hours may be necessary based on company needs. The Medical Management Specialist I responsible for providing non-clinical support to the Care Coordination Team. How you will make an impact. Primary duties may include, but are not limited to: * Gathers clinical information regarding case and determines appropriate area to refer or assign case (utilization management, case management, QI, Med Review). * Provides information regarding network providers or general program information when requested. * May assist with complex cases. * Prepares reports and documents all actions. * Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information. * Receive incoming member and provider calls and provide support with basic information and triage other issues to the appropriate location. * Conduct member and provider outreach to follow up on activities of care coordination. * Confirm service initiation and coordinate service delivery. * Support Care Coordinators with scheduling visits and collecting information from providers. * Help members with scheduling transportation and accessing community resources. * Facilitate exchanges of documentation between interdisciplinary teams. Minimum Requirements: * Requires a H.S. diploma or equivalent and a minimum of 1 year experience or any combination of education and experience which would provide an equivalent background. Preferred Qualifications: * Understanding of managed care or Medicaid/Medicare strongly preferred. * Call center or other phone-based customer service experience strongly preferred. For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ******************************************** for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

**Seeking candidates who have an active, unrestricted RN Compact license or Multi-state RN licenses in either of the following states: AZ, FL, IA, IN, KS, MA, NM, OH, TN, TX or VA.** **Carebridge Health** is a proud member of the Elevance Health family of companies, within our Carelon business. Carebridge Health exists to enable individuals in home and community-based settings to maximize their health, independence, and quality of life through home-care and community based services **Work Location:** **Virtual** This role enables associates to work virtually full-time, with the exception of required in-person training sessions (when indicated), providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. **Work Shift:** **Overnight 10pm - 8am (Central Standard Time)** The RN will work eight (8)10-hour work shifts, in a two-week period which includes Saturday and Sunday every other weekend. The **Triage Nurse I - CareBridge** is responsible for determining the appropriate Care Management program for members referred through internal and external sources and various data sources and reports. Utilizing department guidelines, completes triage process and applies established criteria to assign members to appropriate care management component. Deals with least complex cases having limited or no previous Triage care experience. Primary duties may include but are not limited to: + Utilizes the nursing process to meet an individual's health needs, utilizing plan benefits and community resources. + Educates members about contracted physicians, facilities and healthcare providers. + Learn to develop favorable working partnerships and collaborative relationships with members, physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members. + Works in collaboration with medical management and care management associates to identify issues, problems, and resource needs and assign to appropriate care management program. + Facilitates selecting appropriate candidates for referral to CM and/or DM. + Partners with social work as appropriate. + Identifies and refers cases or issues to QI, SIU, Subrogation, Underwriting, or other departments as appropriate. + Documents appropriate clinical information, decisions, and determinations in a timely, accurate, and concise manner. + Develops a working knowledge of member benefits, contracts, medical policy, professional standards of practice, and current health care practices. Position requirements: + Requires AS in nursing and minimum of 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 the applicable state(s) required. Preferred qualifications, skills, and experiences: + Current, active, RN Compact license highly preferred. + Emergency Room and/or Urgent Care experience highly preferred. + Telehealth experience. + Experience with EMR systems. + BS in nursing preferred. + Participation and/or certification in a managed care or utilization management organization preferred. + Ability to understand clinical information and prepare a concise summary following department standards strongly preferred. + Basic knowledge of the medical management and care management process and role preferred. For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $65,600 to $113,160 Locations: Cleveland, OH; Columbus, OH; Massachusetts In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws _._ * The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law. Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ******************************************** for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015. Position Summary The Senior Medical Economics Analyst - Pharmacy is responsible for performing advanced analytical work to evaluate pharmacy utilization, drug cost trends, and program performance. This role provides strategic insights to support pharmacy benefit design, formulary management, and value-based initiatives. The analyst partners closely with pharmacy, actuarial, clinical, and finance teams to identify cost-saving opportunities and improve overall healthcare value. Job Description Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization. * Analyzes pharmacy claims and utilization data to identify cost and utilization drivers, drug mix shifts, and emerging trend patterns. * Evaluates the financial impact of formulary changes, rebate programs, and utilization management strategies (e.g., prior authorization, step therapy). * Conducts ROI analyses for pharmacy interventions, clinical programs, and vendor initiatives. * Supports annual pharmacy budget and forecast processes, including trend projections and variance explanations. * Develops and maintain regular pharmacy trend and performance reports for internal stakeholders and executive leadership. * Provides actionable insights to inform drug formulary decisions, rebate negotiations, and medical-pharmacy integration strategies. * Creates dashboards and visualizations to communicate pharmacy spend trends, key performance indicators (KPIs), and cost savings opportunities. * Partners with the pharmacy operations, clinical pharmacy, and contracting teams to assess the financial impact of drug pricing and utilization policies. * Works with clinical teams to evaluate the total cost of care and identify opportunities for better integration between medical and pharmacy benefits. * Collaborates with data analytics and IT teams to enhance pharmacy data integrity, automation, and analytics capabilities. Requirements: * Bachelor's degree in business, health administration, health policy, finance or a related field required. * 5+ years of managed care or similar experience including managed care finance, medical economics, pharmacy management, and clinical program cost-effectiveness analytics. * Experience working with actuarial/pricing and other key financial departments. Knowledge, Skills, & Abilities: * Knowledge of or experience with Medicare Advantage programs. * Knowledge of or experience with medical cost, clinical or provider contracting analysis. * Excellent oral, written and presentation skills to support management briefings and presentations both internal and external. * Demonstrated understanding of and alignment with Martin's Point Values. * Demonstrated proficiency retrieving and manipulating large data sets (SQL, Cognos). * Ability to create insightful dashboards and visual analytics using data visualization tools (Power BI, Tableau). * Ability to develop tools designed to monitor and analyze cost and utilization trends. * Ability creating, reconciling, summarizing, and analyzing data. * Proven ability to organize work, simultaneously work on many activities and projects and meet deadlines directly or through matrix management. * Demonstrated ability to work cross-functionally to develop and implement new programs or services. * Strong track record of building internal and external collaborative relationships. * Broad understanding of managed care business - medical expense trends, financial risk arrangements, medical care management programs, managed care products, risk management. This position is not eligible for immigration sponsorship. We are an equal opportunity/affirmative action employer. Do you have a question about careers at Martin's Point Health Care? Contact us at: *****************************

This job is responsible for ensuring compliance with WellSky's Utilization Management and Quality Improvement Program by serving as a clinical expert on state and federal regulations. The scope of this job includes analyzing and presenting data to establish best practices across post-acute health care settings, including LTACHs, IRFs, SNFs, and Home Health facilities. We invite you to apply today and join us in shaping the future of healthcare! Key Responsibilities: Facilitate activities related to performance measurement and outcomes, ensure the organization meets CMS, NCQA, and other regulatory standards, stay updated on relevant regulatory changes, and support their integration into practices. Generate and validate reports to monitor performance across health plan contracts, ensuring accuracy and alignment with requirements. Conduct regular audits of UM decisions, case documentation, turnaround times, and adherence to other CMS and NCQA requirements. Understand how the UM Program is driven by the NCQA UM standards to ensure UM Program meets all NCQA requirements for accreditation. Prepare and lead committee meetings on a monthly and quarterly basis, driven by NCQA requirements. Prepare detailed quality reports, identify and analyze trends, and present findings to leadership with actionable recommendations. Support implementing corrective action plans when scoring variances occur. Support quality improvement project initiatives. Prepare for regulatory, accreditation, and contractual audits, and contribute to the remediation and documentation of audit findings. Perform other job duties as assigned. Required Qualifications: At least 4-6 years relevant work experience. Experience leading quality improvement projects and committee work. Bachelor's Degree or equivalent work experience. Preferred Qualifications: Active, unrestricted license: RN, PT, OT or SLP, with a bachelor's degree in a related field or a combination of education and experience that includes pertinent clinical experience and advanced working knowledge of CMS standards and guidelines. At minimum, 1-2 years of working knowledge of NCQA UM accreditation standards. Must be able to prioritize, plan and handle multiple tasks and demands simultaneously, with competing deadlines. Excellent in manipulating and sorting data for analytics and reporting. Prior experience owning client compliance SLAs and ensuring success in meeting SLA requirements. Job Expectations: Willing to work additional or irregular hours as needed. Must work in accordance with applicable security policies and procedures to safeguard company and client information. Must be able to sit and view a computer screen for extended periods of time. Travel approximately 10%. #LI-PG1 # Remote WellSky is where independent thinking and collaboration come together to create an authentic culture. We thrive on innovation, inclusiveness, and cohesive perspectives. At WellSky you can make a difference. WellSky provides equal employment opportunities to all people without regard to race, color, national origin, ancestry, citizenship, age, religion, gender, sex, sexual orientation, gender identity, gender expression, marital status, pregnancy, physical or mental disability, protected medical condition, genetic information, military service, veteran status, or any other status or characteristic protected by law. WellSky is proud to be a drug-free workplace. Applicants for U.S.-based positions with WellSky must be legally authorized to work in the United States. Verification of employment eligibility will be required at the time of hire. Certain client-facing positions may be required to comply with applicable requirements, such as immunizations and occupational health mandates. Here are some of the exciting benefits full-time teammates are eligible to receive at WellSky: Excellent medical, dental, and vision benefits Mental health benefits through TelaDoc Prescription drug coverage Generous paid time off, plus 13 paid holidays Paid parental leave 100% vested 401(K) retirement plans Educational assistance up to $2500 per year

Job Details SUN Behavioral Columbus LLC - Columbus, OH Part Time High School/GED None Days Health CareDescription Responsible for the coordination of case management strategies pursuant to the Case Management process. Assists and coordinates care of the patient from pre-hospitalization through discharges. Responsible for assisting with authorization of admissions to hospital. Processes retroactive reviews and appeals, copies needed documentation and writes retro/appeal letters for insurance companies to ensure coverage for patient admissions. Conducts follow up calls with insurance companies to ensure coverage for patient admissions. Participates in performance improvement activities. Attends 80% of staff meetings. Coordinates care for patient through communication with Physicians, Nurse Practitioners, Clinical Services, Nursing, Assessment and Referrals Department. Position Responsibilities: Clinical / Technical Skills (40% of performance review) Provides thorough documentation and timely updates regarding patient status on log sheets that are prepared for daily meetings concerning admissions, reviews and discharges; including case s with limited benefits, cases in peer review/denial and /or unplanned discharges Coordinates with managed care companies or other third-party payors regarding peer reviews, retrospective reviews and appeals. Document s and updates the denial log to reflect same. Consults Business Office and/or admission staff as needed to clarify data and ensure authorization processes are complete. Documents in HCS the results of admission and concurrent reviews. Stays informed about changes in Medicare and Medicaid. Ability to stage local laws, ordinances and practices governing involuntary hospitalization and ensure compliance with same. Reviews the quality of documentation for each level of care to ensure clinical effectiveness and appropriateness of treatment. Maintains an active involvement and awareness of all patient admissions, discharges and transfers to alternate levels of care. Oversees continuity of care for each level of care transition. Develops and maintains processes to minimize denials and communication of same to CFO and Business Office Director. Reports results of daily treatment team meetings all discharges and status of high-risk case such as limited benefits, peer reviews, denials or unplanned discharges. Timely retroactive reviews and appeals within current month Strong knowledge of external review organizations (i.e.: Medicare/Managed Care/Medicaid) with knowledge of payor resources and planning. Types and mails all correspondence in a timely manner. Answers the telephone in a polite manner, Communicates information to the appropriate staff. Interacts with patients/families in a professional manner. Provides explanations regarding statements, insurance coverage. Support discharge planning and utilization review when necessary Perform other duties as required Safety (15% of performance review) Strives to create a safe, healing environment for patients and family members Follows all safety rules while on the job. Reports near misses, as well as errors and accidents promptly. Corrects minor safety hazards. Communicates with peers and management regarding any hazards identified in the workplace. Attends all required safety programs and understands responsibilities related to general, department, and job specific safety. Participates in quality projects, as assigned, and supports quality initiatives. Supports and maintains a culture of safety and quality. Teamwork (15% of performance review) Works well with others in a spirit of teamwork and cooperation. Responds willingly to colleagues and serves as an active part of the hospital team. Builds collaborative relationships with patients, families, staff, and physicians. The ability to retrieve, communicate, and present data and information both verbally and in writing as required Demonstrates listening skills and the ability to express or exchange ideas by means of the spoken and written word. Demonstrates adequate skills in all forms of communication. Adheres to the Standards of Behavior Integrity (15% of performance review) Strives to always do the right thing for the patient, coworkers, and the hospital Adheres to established standards, policies, procedures, protocols, and laws. Applies the Mission and Values of SUN Behavioral Health to personal practice and commits to service excellence. Supports and demonstrates fiscal responsibility through supply usage, ordering of supplies, and conservation of facility resources. Completes required trainings within defined time periods, as established by job description, policies, or hospital leadership Exemplifies professionalism through good attendance and positive attitude, at all times. Maintains confidentiality of patient and staff information, following HIPAA and other privacy laws. Ensures proper documentation in all position activities, following federal and state guidelines. Compassion (15% of performance review) Demonstrates accountability for ensuring the highest quality patient care for patients. Willingness to be accepting of those in need, and to extend a helping hand Desire to go above and beyond for others Understanding and accepting of cultural diversity and differences Qualifications Education Required: High school diploma or GED. CPR and hospital-selected de-escalation technique certification. Preferred: Associates or Bachelors degree. Maintains education and development appropriate for position. May substitute experience for education Experience Required: One year of experience in a behavioral healthcare setting. Preferred: Previous experience in a Utilization Management department or as a Mental Health Tech May substitute education for experience

Who We Are Ready to create a healthier world? We are ready for you! Personify Health is on a mission to simplify and personalize the health experience to improve health and reduce costs for companies and their people. At Personify Health, we believe in offering total rewards, flexible opportunities, and a diverse inclusive community, where every voice matters. Together, we're shaping a healthier, more engaged future. Responsibilities Ready to Connect Members to Care Through Expert Pre-Certification Support? We're seeking a customer-focused professional who can perform critical clerical and administrative duties in the utilization management division while managing high volumes of member interactions with precision and care. As our Utilization Review Intake Specialist, you'll provide accurate information about pre-certification processes while gathering essential demographic and provider data that supports clinical decision-making. This flexible position is ideal for candidates seeking reduced hours while making meaningful impact, with weekend availability required. What makes this role different: ✓ Flexible schedule: Reduced hours with required weekend availability to support healthcare operations and member needs ✓ First impression impact: Serve as initial point of contact for pre-certification inquiries, setting tone for positive member experience ✓ Process expertise: Master pre-certification processes while providing accurate information to internal and external customers ✓ Data integrity: Ensure complete documentation and data accuracy that supports downstream utilization review decision-making What You'll Actually Do Manage customer interactions: Answer and route all incoming phone calls while providing accurate information to internal and external customers regarding pre-certification process. Gather critical information: Collect demographic, non-clinical, and provider data for pre-certification using phone, fax, inter/intranet, and various computer software programs. Review and route requests: Analyze service requests and manage them efficiently, involving appropriate departments as needed for optimal resolution and timely processing. Maintain comprehensive documentation: Perform accurate data entry and maintain complete case information documentation while assisting in document maintenance, revisions, and monthly report compilation. Meet performance standards: Achieve productivity, quality, and turnaround time requirements on daily, weekly, and monthly basis while supporting team excellence. Manage high-volume operations: Handle multiple customer service calls while maintaining logs, files, and organized documentation systems in fast-paced environment. Schedule Requirements Candidates will be assigned one of the below shifts. Tuesday - Saturday, 12:30 - 5pm PST Sunday - Thursday, 12:30 - 5pm PST Qualifications What You Bring to Our Mission The foundational experience: Associate degree preferred in business, management, or related field Prior experience in customer service and/or medical background Prior insurance and/or claims background preferred Experience in medical front office, hospital patient intake, medical claims processing, or equivalent combination of education and experience The technical competencies: Proficiency in Microsoft Excel, Word, and Outlook Accurate data entry skills (40wpm minimum) Knowledge of medical terminology; ICD-10, CPT & HCPCS coding desirable Ability to navigate various computer software programs for data collection and documentation The professional qualities: Strong written and verbal communication skills for diverse customer interactions Ability to manage high volumes of customer service calls while maintaining quality and accuracy Capability to organize, prioritize, and multitask in fast-paced, deadline-driven environment Demonstrate ability to work independently with excellent judgment and decision-making Strong customer orientation with commitment to providing accurate, helpful information Flexibility to work weekends as required to support operational needs Adaptability to changing priorities and ability to involve appropriate departments for complex requests Why You'll Love It Here We believe in total rewards that actually matter-not just competitive packages, but benefits that support how you want to live and work. Your wellbeing comes first: Comprehensive medical and dental coverage through our own health solutions (yes, we use what we build!) Mental health support and wellness programs designed by experts who get it Flexible work arrangements that fit your life, not the other way around Financial security that makes sense: Retirement planning support to help you build real wealth for the future Basic Life and AD&D Insurance plus Short-Term and Long-Term Disability protection Employee savings programs and voluntary benefits like Critical Illness and Hospital Indemnity coverage Growth without limits: Professional development opportunities and clear career progression paths Mentorship from industry leaders who want to see you succeed Learning budget to invest in skills that matter to your future A culture that energizes: People Matter: Inclusive community where every voice matters and diverse perspectives drive innovation One Team One Dream: Collaborative environment where we celebrate wins together and support each other through challenges We Deliver: Mission-driven work that creates real impact on people's health and wellbeing, with clear accountability for results Grow Forward: Continuous learning mindset with team events, recognition programs, and celebrations that make work genuinely enjoyable The practical stuff: Competitive base salary that rewards your success Unlimited PTO policy because rest and recharge time is non-negotiable Benefits effective day one-because you shouldn't have to wait to be taken care of Ready to create a healthier world? We're ready for you. No candidate will meet every single desired qualification. If your experience looks a little different from what we've identified and you think you can bring value to the role, we'd love to learn more about you! Personify Health is an equal opportunity organization and is committed to diversity, inclusion, equity, and social justice. In compliance with all states and cities that require transparency of pay, the base compensation for this position ranges from $15 to $18 per hour. Note that compensation may vary based on location, skills, and experience. This position is part time and therefore not eligible for benefits. We strive to cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive. Personify Health is committed to driving Diversity, Equity, Inclusion and Belonging (DEIB) for all stakeholders: employees (at each organization level), members, clients and the communities in which we operate. Diversity is core to who we are and critical to our work in health and wellbeing. #WeAreHiring #PersonifyHealth #TPA #HPA #Selffunded Beware of Hiring Scams: Personify Health will never ask for payment or sensitive personal information such as social security numbers during the hiring process. All official communication will come from a verified company email address. If you receive suspicious requests or communications, please report them to **************************. All of our legitimate openings can be found on the Personify Health Career Site.

Job DescriptionDescription: The Utilization Management Representative is responsible for coordinating cases for prior authorization reviews, ensuring compliance with organizational and regulatory requirements. Need to communicate clearly and professionally with members, providers, and internal departments. This full-time position requires excellent customer service skills, strong attention to detail, and the ability to analyze situations effectively to ensure timely and accurate case processing. The role involves verifying insurance for DME supplies, submitting prior authorizations, requesting documentation, following up on documentation requests, processing orders for shipment and maintaining positive customer relations while adhering to company policies and procedures. HIRING REMOTE EXPERIENCED CSR'S IN THE FOLLOWING STATES: AL FL, GA, IN, KY, LA, MS, NC, SC, TN, TX, VA, & WV Responsibilities • Incoming/Outgoing calls • Review contract and benefit eligibility. • Refer cases requiring clinical review to internal review and/or submit to insurance provider for prior authorization •Data entry • Respond to telephone and written inquiries from members, providers, Manufacturers, and in-house departments., • Conduct clinical screening processes., • Request clinical documents from Providers, Follow up on requested documentation • Develop and maintain positive customer relations and coordinate with various functions within the company., • Participate in developing department goals, objectives, and systems., • Attend staff meetings and other meetings and seminars as assigned., • Recommend new approaches, policies, and procedures to improve department efficiency., • Perform other related duties as assigned. Requirements: Minimum of 2 year's DME experience and/or 2 years Utilization Management experience required (any combination) Proven high-quality customer service skills for internal and external customers. Excellent organizational skills and attention to detail. Ability to prioritize tasks and communicate effectively to groups. Proficient with Microsoft Office Suite - satisfactory completion of our skills testing is required. High school diploma or GED required. Equipment is not provided.

The UM Clinical Specialist-Behavioral Health performs professional and administrative work, primarily utilization reviews, utilization management and active care management to ensure economical and effective consumer service delivery by PHIP enrolled network providers; The position is responsible for providing medical necessity reviews of individualized service plans and requests for authorization of services to ensure consumers receive services in the least restrictive, most integrated setting appropriate to the individual's needs; The primary role is to review for services under the Medicaid B waiver and state funded benefits; complete related work as required. This position will allow the successful candidate to work a schedule that will be primarily remote. While there is no expectation of being in the office routinely, they will be required to come into the Alliance Office for business and team meetings as needed. Responsibilities & Duties Utilization Reviews and Management Independently conducts medical necessity reviews of service requests submitted by service providers against developed clinical guidelines within contractually mandated turn-around times Conducts utilization reviews to monitor adherence to clinical practice guidelines and best practice standards and to determine if services were delivered as requested Engage in care management activities to ensures individuals receive appropriate referral for treatment including; consumer and provider follow-up calls, case staffing with psychologists and medical staff Monitors consumer person centered plans to ensure that effective treatment interventions are utilized, provide consultation to treating providers when person centered plan requires adjustments to better meet consumer needs Monitors and reports consumer and provider specific over/under utilization Conducts utilization reviews to monitor for over/under utilization Program Operation and Management Identify high risk consumers and those with special health care needs for referral to Care Coordination and case escalation Provides linkage, authorizations and level of care determinations, assisting providers and Care Coordinators with creative problem solving to recommend alternative approaches to care Ensures compliance with care management and quality improvement policies and procedures, utilization review laws and regulations, state standards Promote access to appropriate, effective and quality treatment Monitors for undesirable performance or deviations of practice standards through care management activities that may have a negative impact on consumers. Responds through additional follow-up with consumer and providers, provider technical assistance and/or referral to other departments within the MCO Administrative Functions Notifies members of adverse benefit determinations while preserving members' Due Process rights Engages in routine follow-up to ensure consumers are engaged in treatment and services are being delivered as requested Documents utilization review decisions in computerized authorization management system Maintain professional licensure Engages in training as needed to stay informed of changes in best practice for supporting the needs of individuals with MH/SUD/IDD Minimum Requirements Education & Experience : Master's degree in a Human Services field (such as Psychology, Social Work or Counseling) and at least five years of post-degree progressive experience providing similar services to the population served (MH/SUD). Requires current and active license issued by a North Carolina Professional Board, as a LCSW, LCAS, LP, LPA, LMFT, LCMHC or RN. OR A master's degree in psychiatric nursing which provides the knowledge, skills, and abilities needed to perform this work; or graduation from a State accredited school of nursing and two years of experience in psychiatric nursing which provides the knowledge, skills, and abilities needed to perform the work; or an equivalent combination of education and experience. Preferred: Experience in the public behavioral healthcare field is highly desired due to the complexity of the work. Experience in a UM environment in Behavioral Healthcare would be valuable for this employee. Knowledge, Skills, & Abilities Considerable knowledge of case management principles, practices and applications Considerable knowledge of agency and community programs and services which affect clients and applicants Knowledge of state and federal client rights protection statues and regulations applicable laws and regulations including but not limited to URAC, applicable Code of Federal Regulations and NC Administrative Code Effective written and oral communication skills and interpersonal and presentation skills Ability to identify rights protection complaint issues; ability to set, monitor and evaluate standards for quality and to assess plans to measure how they meet the needs of individual clients Considerable knowledge in DMS 5 diagnostic criteria Ability to manage time, prioritize work and use problem-solving approaches Ability to coordinate effectively with staff from a various agencies as well as inter-departmental Ability to read, analyze, and interpret regulations, policies and procedures Coordinate work with a variety of individuals and agencies Ability to operate computer equipment and generate reports and records; ability to express ideas clearly and concisely orally and in written documents Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) is required Salary Range $68,227 - $86,990/Annual Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity. An excellent fringe benefit package accompanies the salary, which includes: Medical, Dental, Vision, Life, Long Term Disability Generous retirement savings plan Flexible work schedules including hybrid/remote options Paid time off including vacation, sick leave, holiday, management leave Dress flexibility

Who We Are - Motivated by Purpose. Powered by Clinical Expertise. Founded in 1983, we're a clinically-driven, tech-enabled utilization management company offering expert clinical reviews, regulatory guidance, and actionable insights to healthcare organizations. Excellence starts with our people. Why Join MRIoA? We provide: Top-Tier Benefits & Support - We invest in you-through competitive compensation, comprehensive benefits, continued education, and flexible work options. A Tech‑Driven Culture with Heart - We are a clinician-guided, tech-driven utilization management company with a culture that is approachable, collaborative, and dedicated to excellence. Growth Opportunities - Whether you're a care reviewer, clinician, or operations specialist, you'll have access to meaningful development and mentorship MRIoA's health care benefits provide coverage when it's needed - with a focus on programs that support and encourage healthy living and your overall well-being. Our benefits include: Fully remote Medical Dental Vision Paid Time Off (PTO) Paid Sick Leave (PSL) Paid Holidays Profit Sharing 401(k) Savings Plan Short-Term and Long-Term Disability Tuition and Scholarship Assistance Voluntary Life Insurance Pet Health Insurance Position Summary We are seeking a Scrum Master with deep expertise in software engineering, agile delivery, and people management to lead design, development, and implementation of scalable, cloud-native technology solutions. This role combines technical leadership, team management, and delivery accountability, driving engineering excellence across the full lifecycle - from architecture and design through release and operations. You will partner closely with product, architecture, IT, and business/operations leaders to deliver innovative, compliant, and high-performing solutions to market. The ideal candidate is an accomplished leader with a technology background who can roll up their sleeves with React, Node.js, SQL Server, etc. in Azure while guiding teams through complex architectural decisions involving microservices, micro frontends, microapps, BFF (Backend-for-Frontend) layers, and event-driven systems. This person will demonstrate an ownership mindset, a passion for quality, and a strong commitment to delivering business outcomes on time and within budget. Roles and Responsibilities Technical Leadership & Design Oversight Provide architectural and design oversight, influencing system decisions for scalability, maintainability, observability, and performance. Define and enforce coding standards, design patterns, and development best practices across all teams. Lead by example with hands-on expertise in React, Node.js, SQL Server, and Azure services. Guide the implementation of microservices, micro frontends, microapps, and event-driven architectures, ensuring consistency and interoperability across the ecosystem. Partner with DevOps to design and optimize CI/CD pipelines, deployment automation, and cloud infrastructure. Lead troubleshooting and defect resolution across the technology stack (frontend, middleware, backend, and database). Anticipate potential technical challenges and proactively implement solutions to mitigate architectural and scalability risks. Manage and plan technical debt remediation alongside new feature delivery. Define and maintain architecture documentation and decision records (ADRs) for continuity and transparency. Ensure robust monitoring, logging, and observability are integral to all design efforts. Oversee integration with vendor or third-party systems, ensuring security, compliance, and performance alignment. Collaborate with internal and vendor teams to develop proofs of concept (POCs) and validate approaches with stakeholders. Agile Delivery & Project Management Serve as Scrum Master for one or more agile teams - facilitating sprint planning, stand-ups, retrospectives, and backlog grooming. Partner closely with Product Owners to ensure epics and user stories are well-defined, prioritized, and achievable. Manage scope, timelines, and budgets, maintaining clear release roadmaps and predictable delivery cadence. Administer and configure Jira to support agile tracking, reporting, and workflow automation. Identify and resolve dependencies, risks, and impediments proactively. Define and track delivery KPIs (velocity, quality, predictability) to ensure accountability and continuous improvement. Align sprint and release planning with broader business and product priorities. Collaborate with PMO and governance functions to ensure visibility, transparency, and compliance in delivery processes. Leadership & Stakeholder Management Lead, mentor, and coach a cross-functional team of developers, QA engineers, and technical leads. Promote a culture of ownership, accountability, and continuous learning within the engineering teams. Communicate complex technical concepts effectively to executives and non-technical stakeholders. Partner with architecture, product, and data teams to ensure alignment with the overall technology roadmap. Develop and grow internal talent, building a succession pipeline for key technical roles. Ensure development goals align with organizational healthcare strategy, including security, privacy (HIPAA), and data protection requirements. Other Assigned Duties Security: Collaborate with IT/IS divisions to ensure adherence to security and data protection standards. Regulatory Adherence: Partner with Compliance to maintain conformity with state, federal, and healthcare-specific regulations. Quality Assurance: Partner with QA and stakeholders to validate that software meets specifications, performance targets, and user expectations. Vendor Management: Coordinate with external development partners to ensure delivery quality and alignment with internal standards. Perform other relevant duties as designated. Work Environment: Ability to sit at a desk, utilize a computer, telephone, and other basic office equipment is required. This role is designed to be a remote position (work-from-home). Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. This company is a drug-free workplace. All candidates are required to pass a Background Screen before beginning employment. All newly hired employees will take a Drug Screen, as well as agreeing to all necessary Compliance Regulations on their first day of employment. Employees are required to adhere to all applicable HIPAA regulations and company policies and procedures regarding the confidentiality, privacy, and security of sensitive health information. California Consumer Privacy Act (CCPA) Information (California Residents Only): Sensitive Personal Info: MRIoA may collect sensitive personal info such as real name, nickname or alias, postal address, telephone number, email address, Social Security number, signature, online identifier, Internet Protocol address, driver's license number, or state identification card number, and passport number. Data Access and Correction: Applicants can access their data and request corrections. For questions and/or requests to edit, delete, or correct data, please email the Medical Review Institute at **************. Skills and Experience: At least 7 years of full-stack software development experience. 3 years of experience in a technical leadership or management role Experience designing and delivering microservices and event-driven architectures at scale Experience with monitoring and observability tools (e.g., Azure Application Insights, Log Analytics, Grafana). Experience with Jira administration and agile project tracking. Hard Skills Knowledge of Database: SQL Server, including performance tuning and schema design. Experience with Backend: Node.js, Express.js, RESTful APIs, event-driven systems. Proficiency in React, TypeScript, and modern JavaScript frameworks. Proficiency with Azure (Functions, App Services, Service Bus, Storage, Azure SQL, CI/CD). Knowledge of API design, versioning, and integration strategies for multi-system environments. Education Bachelor's degree in Computer Science, Engineering, or a related field. Preferred Qualifications Certifications such as Certified ScrumMaster (CSM), PMI-ACP, or Azure Architect are a plus. Master's degree in a technical or management discipline

**Our Organization** Cigna's Data Measurement and Reporting team is a dynamic, rapid and growth focused department. Attention to the execution of a strategic vision for enterprise data, and the delivery of carefully detailed analytics, strengthens our journey to become one of the most customer centric companies in the world. This role sits within the On Demand Reporting Team in Data Measurement and Reporting. The Ad Hoc team is responsible for a variety of functions including standard and custom report fulfillment, **Our Team** The On Demand Reporting Team supports the following reporting tools and fulfillment functions: + Delivers ad hoc medical, pharmacy, clinical, and Cigna program information in the form of reports and extracts to clients, brokers, Sales, Underwriting and other partners + Provides report support for CBH and EAP reports and tools + Provides standard and non-standard tool and report support for our Facets Select clients + Subject matter expertise + HIPAA and policy/procedure workflow management for the fulfillment organization **Core Responsibilities** + Responsible for development, assessment, monitoring, and execution phases of the data analysis process. + Provide comprehensive consultation to business partners throughout the life cycle of a request (document business/technical requirements, create/execute test cases, and facilitate programs from beginning to end). + Follow processes put into place regarding data governance, including but not limited to: + Educating requestors on what is available based on account status + Determining what constitutes minimum necessary for each request + Perform routine and ad hoc (Drill-Down) analysis as it relates operational trending and quality processes. + Maintain the reporting request queue, communicate with requestors, team members, and document all new requests. + Become a subject matter expert on various Cigna products. + Manage high complexity projects, including enhancements + Collaborate with IT partners to ensure new development, enhancements or fixes meet business needs. This includes writing functional requirements, actively participating in system design reviews, reviewing test evidence, and participating in status meetings. + Support management in the long-term strategy and defining of priorities + Demonstrate and maintain deep breadth of knowledge on all product types and business processes + Works independently with little to no guidance on complex issued. + Takes initiative to create processes, procedures, or reports to help with the team/company + Takes on new projects without being asked with little to no complaint + Ability to answer questions with little to no guidance due to knowledge and expertise from research and contacts + Team morale - encouragement and support of other team members. Providing guidance and knowledge. + Cross functional awareness (SME of all trades) + Manage the backlog of projects of medium to large complexity, including enhancements **Ideal Candidates Will Offer:** + Minimum of 5 years' experience in health care/managed care with direct responsibility for analysis and data management with relational database concepts and reporting with strong preference for backgrounds with financial and utilization analysis + BS degree in MIS, Engineering, Mathematics, Statistics, Business, Finance, Economics, Healthcare, Computer Science or equivalent mastery and training. Advance degree preferred + In-depth understanding of managed care business processes, data (ETG, EBM, ICD10, CPT4, DRG, etc.), systems, case-mix adjustment, and applications for claims payment, providers, and utilization management. + Expertise in the use of relational database concepts and applications, specifically use of SAS, SQL, Excel, Hyperion, Toad, Python and QMF + Proficiency with Structured Query Language (SQL) procedure as a data retrieval tool. Specifically, the ability to write programs to perform queries on data and retrieve data from multiple tables/sources with SAS and SQL + Ability to navigate organization, build SME relationships and assist with internal discussions and effectively represent subject matter expertise + Demonstrate experience and complete all required testing across multiple data systems, including all testing planning and execution of pilots of new data feeds or infrastructure changes + Experience with continuous quality improvement methods and tools + Strong healthcare data experience and demonstrated understanding of the health delivery system. + Proven experience in interpreting and translating complex business needs into technical requirements + Strong data mining skills including the ability to perform research and conduct root cause analyses. + Proven ability to effectively negotiate and solve problems in a complex organization + Demonstrated excellent communication and interpersonal skills and ability to effectively organize/present information to various audiences to coordinate new business solutions + Ability to quickly understand key aspects of data and applications as they relate to business functions + Ability to work effectively independently, within a team or with matrix partners with some guidance while managing multiple tasks and meeting aggressive deadlines + Comprehensive understanding of claim submissions claims payment processes, reporting concepts, database management, and financial concepts extremely helpful. + Demonstrated leadership competencies with the ability to collaborate with others, establish working relationships and communicate effectively across the organization and at different levels. If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload. For this position, we anticipate offering an annual salary of 94,600 - 157,600 USD / yearly, depending on relevant factors, including experience and geographic location. This role is also anticipated to be eligible to participate in an annual bonus plan. We want you to be healthy, balanced, and feel secure. That's why you'll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you'll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group . **About The Cigna Group** Doing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we're dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients. Join us in driving growth and improving lives. _Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws._ _If you require reasonable accommodation in completing the online application process, please email:_ _*********************_ _for support. Do not email_ _*********************_ _for an update on your application or to provide your resume as you will not receive a response._ _The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State._ _Qualified applicants with criminal histories will be considered for employment in a manner_ _consistent with all federal, state and local ordinances._

Availity delivers revenue cycle and related business solutions for health care professionals who want to build healthy, thriving organizations. Availity has the powerful tools, actionable insights and expansive network reach that medical businesses need to get an edge in an industry constantly redefined by change. At Availity, we're not just another Healthcare Technology company; we're pioneers reshaping the future of healthcare! With our headquarters in vibrant Jacksonville, FL, and an exciting office in Bangalore, India, along with an exceptional remote workforce across the United States, we're a global team united by a powerful mission. We're on a mission to bring the focus back to what truly matters - patient care. As the leading healthcare engagement platform, we're the heartbeat of an industry that impacts millions. With over 2 million providers connected to health plans, and processing over 12 billion transactions annually, our influence is continually expanding. Join our energetic, dynamic, and forward-thinking team where your ideas are celebrated, innovation is encouraged, and every contribution counts. We're transforming the healthcare landscape, solving communication challenges, and creating connections that empower the nation's premier healthcare ecosystem. We are seeking a Senior Product Manager with expertise in Utilization Management (UM) and prior authorization workflows. This role will focus on developing and enhancing UM solutions that streamline prior authorizations, medical necessity reviews, and payer-provider workflows while ensuring compliance with regulatory guidelines. The ideal candidate will bridge the gap between business, clinical, and technical teams to optimize utilization management processes and reporting capabilities. Sponsorship, in any form, is not available for this position. Why you want to work on this team: You will have the opportunity to work on a cutting-edge solution that has the potential to reshape the way utilization management processes are handled in the industry. Utilization Management is a hot topic in the healthcare industry and Availity is well positioned as a bridge between payers and providers to make the process better for both parties. The work that the team is doing is one of disruption, accountability, and doing the right thing which equates to meaningful work. To be qualified for this position you have: Extensive experience in utilization management (UM). Candidates without UM experience would not be considered. Strong clinical background: inpatient and outpatient. Strong understanding of prior authorizations workflows, medical necessity reviews, and payer policies. This is required to be considered for the role. Knowledge of EHRs, claims processing systems, and utilization management platforms. Business acumen: ability to contribute to a business case, evaluate feasibility & scalability, ability to assess and drive ROI, background in contracting. Experience with AI-driven UM solutions and automation technologies. Strong understanding of utilization metrics, value-based care models, and population health analytics. Knowledge of regulatory and accreditation requirements. Ability to drive work with limited oversight. Desire to work in a fast-paced environment, with multiple competing priorities. You will set yourself apart with: Healthcare technology background. Product background highly preferred. Proficiency in analyzing data and finding actionable insights. Ability to manage ambiguity in a fast-paced environment. Hands-on experience with Tableau or other tools for reporting, data visualization, and healthcare analytics. Familiarity with coding (CPT codes) and payment accuracy. What you will be doing: Building business requirements for various product enhancements. Prioritizing additional product features to drive client adoption and speed to market. Managing pilot oversight to include working with pilot partners to drive business requirements, creating and monitoring KPI/OKR's, GTM planning, scaling, etc. Liaising to clinical team for CPT and Medical policy questions. Acting as the Utilization Management workflow SME. Prioritizing product feature build based on industry trends, client feedback, speed to value while balancing the overall product roadmap. Revamping standard client reporting package; be a business SME for data team to drive clarity in reporting needs. Building out product performance reporting, including specific client views (foundation for ROI and gainshare) and overall product performance. Serving as a SME for UM benchmarking for client specific opportunity analysis and client reporting against metrics. Supporting sales, marketing and client success teams by providing product demos, training, and analytics driven insights. Working with the delivery team after contract signature. Availity culture and benefits: Availity is a certified “Great Place to Work”! Culture is important to us and there are many ways for you to make your mark here! We have several Diversity & Inclusion teams, a Young Professionals Group, a She Can Code IT group for women in tech, and various ways to engage with fellow Availity associates. Availity is a culture of continuous learning. We have many resources and experts in our tech stack and in our industry that can help get you there too! Don't feel like wearing business attire? Cool, you can wear jeans - we are a casual place. We offer a competitive salary, bonus structure, generous HSA company contribution, healthcare, vision, dental benefits and a 401k match program that you can take advantage of on day one! We offer unlimited PTO for salaried associates + 9 paid holidays. Hourly associates start at 19 days of PTO and go up from there with all the same holiday benefits. Interested in wellness? We allow our associates to reimburse up to $250/year for gym memberships, participation in racing events, weight management programs, etc. Interested in furthering your education? We offer education reimbursement! Availity offers Paid Parental Leave for both moms and dads, both birth parents and adoptive parents. Want to work for an organization that gives back to the community? You're at the right place! Availity partners with various organizations, both locally and nationally, to raise awareness, funds and morale as our staff members volunteer their time and funds to engage the organizations campaign. Next steps: After you apply, you will receive text/email messages thanking you for applying and then you will continue to receive more text/email messages alerting you as to where you are in the recruitment process. Interview process: Recruiter Recorded Video Pre-Screen Video Interview with Hiring Manager Panel Video Interview Final Video with Hiring Manager Video Camera Usage: Availity fosters a collaborative and open culture where communication and engagement are central to our success. As a remote first company, we are also camera-first and provide all associates with camera/video capability to simulate the office environment. If you are not able to use your camera for all virtual meetings, you should not apply for this role. Having cameras on helps create a more connected, interactive, and productive environment, allowing teams to communicate more effectively and build stronger working relationships. The usage of cameras also enhances security and protects sensitive company information. Video participation is required to ensure that only authorized personnel are present in meetings and to prevent unauthorized access, data breaches, preventing social engineering, or the sharing of confidential information with non-participants. Disclaimers: Availity is an equal opportunity employer and makes decisions in employment matters without regard to race, religious creed, color, age, sex, sexual orientation, gender identity, gender expression, genetic information, national origin, religion, marital status, medical condition, disability, military service, pregnancy, childbirth and related medical conditions, or any other classification protected by federal, state, and local laws and ordinances. Availity is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. NOTICE: Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. When required by state law or federal regulation, Availity uses I-9, Employment Eligibility Verification in conjunction with E-Verify to determine employment eligibility. Learn more about E-Verify at *************************** . Click the links below to view Federal Employment Notices. Family & Medical Leave Act Equal Employment Law Poster Pay Transparency Employee Polygraph Protection Act IER Right to Work Poster Important Notice about Employee Rights to Organize and Bargain Collectively with Their Employers

About Intus Care IntusCare is the only end-to-end ecosystem built specifically to help Programs of All-Inclusive Care for the Elderly (PACE) programs deliver exceptional care, strengthen financial performance, and stay compliant. IntusCare replaces outdated technology and manual workarounds with purpose-built solutions for care coordination, risk adjustment, population health, and utilization management. IntusCare empowers teams to take control of their operations and improve outcomes for dual-eligible seniors - some of the most socially vulnerable and clinically complex individuals in the U.S. healthcare system Role Overview: As an Software Development Engineer in Test, you will play a vital role in ensuring the quality and reliability of our healthcare software solutions. You will develop and implement automated testing frameworks, collaborate with cross-functional teams in an agile environment, and contribute to the continuous improvement of our testing processes. Your expertise will help us deliver high-quality products that enhance patient care and streamline healthcare operations. Responsibilities: Design, develop, and maintain automated test frameworks and scripts for our web and mobile applications Collaborate with developers, product managers, and other stakeholders to understand product requirements and create comprehensive test plans Execute manual and automated tests, including functional, integration, and regression testing Identify, report, and track software defects using our bug tracking system Participate in code reviews and contribute to improving the overall quality of our codebase Assist in the continuous improvement of our QA processes and methodologies Stay up-to-date with the latest testing tools, technologies, and best practices in the healthcare software industry Qualifications: Bachelor's degree in computer science, Software Engineering, or a related field 3-6 years of experience in software testing or quality assurance, preferably in a healthcare or startup environment Strong programming skills in at least one language (eg., Python, Typescript, or JavaScript) and SQL Experience with test automation frameworks and tools (eg. Cypress, or Playwright) Familiarity with API testing and tools like Postman Knowledge of software development methodologies (eg., Agile, Scrum) Excellent problem-solving and analytical skills Strong communication and teamwork abilities Preferred Skills: Experience with healthcare software or familiarity with HIPAA compliance Knowledge of version control systems (eg., Git) and CI/CD pipelines Experience with performance testing tools (eg. k6) Familiarity with cloud platforms (eg., AWS, Azure or GCP) Understanding of database systems and SQL Benefits Competitive salary and benefits package including uncapped PTO and health insurance Opportunity to work with a passionate and innovative team Professional development and growth opportunities Flexible work environment Compensation: The salary range for this role is $100K-$120K. We expect the ideal candidate to fall near the midpoint of this range, though final compensation will be determined based on experience, skills, and organizational needs. Work location: This is a fully remote role based in the United States. Sponsorship: This position is not eligible for sponsorship.

Clinical Assistant needs 2 plus years of experience into customer service, medical terminology, and history with medical related jobs. Clinical Assistant requires: High School Diploma or equivalent Experience COVID vaccinated maybe required 1 year - Customer service experience is required Skills\Certifications Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint) Proficient oral and written communication skills o Proficient interpersonal and organizational skills o Exceptional time management skills Ability to work independently under general supervision and collaboratively as part of a team in a fast paced environment Independent, Sound decision-making and problem-solving skills Extensive knowledge of all aspects of Utilization Management, Care Management, and Behavioral Health. Knowledge and understanding of Medical terminology Solid knowledge and understanding of provider reimbursement methodologies, ICD-9-CM, CPT, HCPCS and UB-92 coding, UHDDS coding guidelines, AHA Coding Clinic Ability to talk and type simultaneously in a clear and concise manner while interacting with customers Participation and attendance are mandatory. Requires flexibility, due to rotations in schedules, and requires adherence to assigned schedules. Clinical Assistant duties: Screen incoming calls and/or faxes or other digital format and direct calls/faxes/other digital requests to the appropriate area. Identify and refer cases appropriately to the Case Management and/or Transition of Care department. Receive, investigate and resolve customer inquiries and claims. Maintain departmental goals. Perform projects, review and handle reports as assigned. Load complete organization determination/notification for services designed by internal policy. Clearly document and key data in to the appropriate system using departmental guidelines. Interact with membership, hospital and provider staff, advising of decision, status organization determinations, giving direction as necessary. Search for and key appropriate diagnosis and /or procedure code as part of the notification /prior authorization process. Must be able to pass required testing.

It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances. Job Summary: Responsible for managing assigned territory of professional, institutional and ancillary providers to develop and enhance relationships, making WellSense Health Plan their plan of choice. Serves as the primary liaison between WellSense and key provider organizations, taking the lead and promoting collaboration within WellSense as it relates to provider satisfaction. Manages territory of assigned network partnerships, that may include Special Kids Special Care (SKSC) providers, HRSN (Health Related Social Needs) providers, primary care providers, specialists, facilities, community health centers, ancillary providers, and labs. Works closely with the Sr. Provider Relations Consultants and the Provider Relations Manager to identify issues and report trends. Acts as the primary liaison between the providers and internal WellSense departments including Provider Enrollment, Member Enrollment, Member & Provider Services, Claims, Audit, Marketing, Utilization Management and Care Management. Our Investment in You: · Full-time remote work · Competitive salaries · Excellent benefits Key Functions/Responsibilities: Develops and enhances relationships with assigned providers to including primary care providers, community health centers and hospital systems through effective business interactions and outreach. Collaborates with various WellSense departments to ensure accurate provider data and timely payment of claims, consistent with the plan's policies and procedures. Identifies system changes or trends impacting claims processing and payments and works internally on resolution. Produces reports as needed to support provider education, servicing, credentialing and network maintenance. This includes Provider Demographic reports, Panel Reports, Claim Detail reports, etc. Assists in the development of provider presentations that clearly communicate plan information and updates. Delivers presentations to provider groups, health systems, and provider forums. Meets with assigned providers regularly according to site visit servicing standards. Documents all pertinent provider communications and meeting notes in the customer relationship portal. Acts as liaison for all issues with provider to include, reimbursement, credentialing, claims, portal procedures, and issues of assigned providers. Facilitates resolution of complex contractual and member and provider issues, collaborating with internal departments as necessary Outreaches to providers to support WellSense initiatives and assigned projects. Supports providers on Member grievance questions and process. Provides education, training, and support on WellSense products, policies, procedures, web portal, and operational issues. Manages timely responses to and from internal departments to ensure effective communication regarding updates. Identifies system issues and updates needed; completes research related to provider data in plan systems. Manages flow of information to and from provider offices. Ensures active provider contacts are collected and in the Plan's system for effective mailing of plan notices and communication. Ensures quality and compliance with State Agencies and NCQA. Other responsibilities as assigned. Regular and reliable attendance is required. Supervision Exercised: · None Supervision Received: Indirect supervision is received weekly. Qualifications: Education: Bachelor's degree in business administration or a related field or an equivalent combination of education, training and provider relations or network management experience is required. Experience: 2 or more years of progressively responsible experience in a managed care or healthcare environment is preferred. Experience with Medicare and Medicaid Reimbursement Methodologies. Understanding of provider coding and billing practices. Certification or Conditions of Employment: Successful completion of pre-employment background check. Competencies, Skills, and Attributes: Experience with ICD-10, CPT/HCPCS Codes, and billing claim forms. Ability to work as a team member, manage multiple tasks, be flexible, work independently, be pro-active, think outside the box, and possess excellent organizational skills. Proven expertise utilizing Microsoft Office products. Effective communication skills (verbal and written). Strong follow-up skills a must. Proficient in multi-tasking. Ability to set and manage priorities and thrive in a fast-paced environment. Working Conditions and Physical Effort: Must be willing to travel to assigned providers for servicing to meet business needs up to 50% of time Must be able to travel to multiple provider offices across a wide geographic area on a regular basis, often within the same day. In office work performed in a typical remote home office environment. About WellSense WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

Join Our Team as a Utilization Review Manager (RN or Social Worker) Are you a compassionate nurse or social worker looking to make a real difference in behavioral health? AllHealth Network is seeking a dedicated Utilization Review Specialist to help ensure clients receive the care they need while collaborating with a team that values your expertise and commitment. Why AllHealth Network? * Work in a supportive, interdisciplinary environment that values your professional judgment * Enjoy opportunities for ongoing learning, growth, and advancement * Make a tangible impact on client outcomes and community well-being * Be part of a mission-driven organization dedicated to high-quality, client-centered care What You'll Do: * Advocate for clients by communicating clinical information to secure timely and appropriate care authorizations * Lead utilization reviews for clients in our Acute Treatment and Crisis Stabilization Units * Collaborate with nurses, social workers, case managers, and other healthcare professionals * Ensure quality care by coordinating with payers, treatment teams, and billing staff * Maintain accurate records and use your problem-solving skills to navigate challenging cases What We're Looking For: * Registered Nurse (BSN/RN) or Master's in a human services field * Clinical license (LPC, LCSW) required * Minimum 2 years' experience in behavioral health utilization management, care coordination, or case management * Strong communication, organization, and advocacy skills * Experience with insurance processes, electronic records, and multidisciplinary teamwork Ready to take your career to the next level with a team that cares as much as you do? Apply today and help us transform lives-one client at a time. $72,000 - $80,000 annually AllHealth Network also provides a 10% compensation differential for individuals who are bilingual in English and Spanish (language proficiency testing required). The base salary range represents the low and high end of the AllHealth Network hiring range for this position. Actual salaries will vary and may be above or below the range based on various factors including but not limited to experience, education, training, merit, and the ability to embody the AllHealth Network mission and values. The range listed is just one component of AllHealth Networks' total compensation package for employees. Other rewards may include short-term and long-term incentives as well as a generous benefits package detailed below.