Determine that the case is assigned to the appropriate team for review (e.g., Medicare, Medicaid, Commercial) Validate that cases/requests for services require additional research Identify and utilize appropriate resources to conduct non clinical research (e.g., benefit documents, evidence of coverage, state/federal mandates, online resources) Prioritize cases based on ap

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

Financial management of Lease accounting prepare, document and record lease transactions, including transactions that require technical accounting Fixed asset accounting and asset management close out projects, create assets, maintain appropriate useful life of asset, manage depreciation schedules, evaluate capitalization versus expense A suite of real estate based balanc

Full oversight of the specialty sale at the direction of the AE/SAE to achieve health plan market sales goals and maintain profitability Advocate for specialty voluntary products to support increase in enrollment and size of sale and negotiate based on broker/customer feedback with underwriting; leveraging rate bank, product discount programs and packaged savings to lever

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

Perform thorough telephonic nursing assessment and clinical review to determine appropriate triage protocol to utilize for nurse care advice. Ensure member is directed to appropriate level of care at contracted facilities. Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, least restrictive level of care

Receive assigned medical charts to code Review medical charts electronically Abstract and code diagnosis and documentation information Document requested information from the medical record Perform ongoing analysis of medical record charts for the appropriate coding compliance The key challenge of this role centers around your ability to work quickly, accurately and indep

Assess, plan and implement care management interventions that are individualized for each patient and directed toward the most appropriate, least restrictive level of care Identify and initiate referrals for both healthcare and community based services; including but not limited to financial, psychosocial, community and state supportive services Develop and implement care

Serve as a liaison for post transition concerns Aid members who lose nursing facility level of care or are ready for discharge from a nursing facility to ensure a successful discharge or transfer to another residential setting Work with the Member Advocate Coordinator and other member focused departments Outreach to and engage a member transitioning between programs to co

Partner with community providers of peer support to expand the network and ensure quality services are available for our members Educate by creating new curriculum specific to state need and facilitate community trainings Model the principles of recovery and provide member perspective to our CM, UM, Network, Product and Affordability partners Advocate for a recovery persp

Works to ensure that internal processes are executed, especially related to intersegment responsibilities, for fraud, waste, and abuse (FWA) vendors' instances of health care FWA by medical profession or insured member Acts as FWA subject matter expert for Federal and local FWA regulations and subsequent regulatory policy and process implementation Keeping apprised of cur

Provide an exceptional customer service experience when responding to and resolving customer service inquires and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility and claims, financial spending accounts and correspondence Research complex issues (such as Medical, Dental, Flex Spending, Pharmacy, etc.) across multiple da

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, c

Test Data Provision & Masking Operation Test data need & masking analysis ( Data structure, SQL queries) Working with Informatica tool to configure & invoke Data Copy and Masking jobs and maintain Gold Copy Maintenance of TDM Portal using UNIX scripting, Java Spring boot and Angular You'll be rewarded and recognized for your performance in an environment that will challen

Answer incoming phone calls from customers and identify the type of assistance the customer needs (i.e. benefit and eligibility, billing and payments, authorizations for treatment and explanation of benefits (EOBs) Ask appropriate questions and listen actively to identify specific questions or issues while documenting required information in computer systems Own problem t