Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations Document clinical review findings, actions, and outcomes in accordance with policies, and regulatory and accreditation requirements Engage with requesting providers as needed in peer to peer discussions Be knowledgeable in

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

Serve as primary care manager for high medical risks / needs members with comorbid behavioral health needs Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic (SDoH) needs Develop and implement individualized, person centered care plans inclusiv

Build an Elite Team of Field Account Managers As a Director of Account Management, you will be responsible for leading a team of Field Account Managers to support execution of the client's daily activities Execution of customer satisfaction and retention Work directly with Strategic Account Executives, Project Manager, and Operation team to ensure your team is executing o

Perform individual case review for appeals and grievances for various health plan and insurance products, which may include PPO, ASO, HMO, MAPD, and PDP. The appeals are in response to adverse determinations for medical services related to benefit design and coverage and the application of clinical criteria of medical policies Perform Department of Insurance/Department of

Consult with users and technology specialists to define business processes and be the liaison between the two parties Perform Business Analysis Ability to define project objective, scope, write business and technical requirements Business Liaison to refine business requirements Communicate and validate requirements with stakeholders Validate solution meets business needs

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

If you reside within Western, KY you will have the flexibility to telecommute as you take on some tough challenges. Primary Responsibilities Functioning independently, travel across assigned territory to meet with providers to discuss Optum tools and programs focused on improving the quality of care for Medicare Advantage Members. Will be out in the field 80% of time in d

Mainly handling inbound calling, NO knocking on doors Answer incoming phone calls from prospective members and identify the type of assistance and information the customer needs with the goal to convert the caller to a qualified lead and ultimately sale Ask appropriate questions and listen actively to identify specific questions or issues while documenting required inform

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 Co

As part of a multi disciplinary care coordination team Addresses the total patient, inclusive of medical, psychosocial, behavioral, cultural, and spiritual needs Involves the individual patient and caregiver, as appropriate, in decision making Facilitates communication and coordination among members of the care team Provides patient care to include patient assessment prio

Develop key internal and external relationships to facilitate results. Understand and create a strategy based on analysis and reporting of sales and market trends, including sales plan execution, competitive intelligence and new product requirements Drive the development of market sales strategies and value proposition formulation Lead as an expert in our national account

Provide skilled nursing care for expectant mothers in the home care environment Travel to provide in home patient care and continuous education to patients and family members Continually assess the mothers' condition to ensure they are safe in the home environment Modify care plans as appropriate based on reassessment, change in prescriber orders, the patient's need for f

Lead a team of Event Planners with effective people leadership through effective coaching, feedback, and people management practices Manage end to end complex conference/event/incentive travel program planning coordination that drives a consistent attendee experience Develop, streamline, and create standards of excellence in designing and executing events while keeping th

Conduct coverage review based on individual member plan documents, and national and proprietary coverage review guidelines, render coverage determinations, and discuss with requesting providers as needed in peer to peer telephone calls Use clinical knowledge in the application and interpretation of medical policy and benefit document language in the process of clinical co