Career Opportunities

JOB SUMMARY Responsible for reviewing prior authorization requests for medical services including elective admissions (Post-Acute and Acute), inpatient surgeries, outpatient surgeries, home health, and durable medical equipment. RN will prioritize expedited requests for medical necessity and efficiency in accordance with health plan coverage guidelines and CMS coverage determinations…

JOB SUMMARY Responsible for reviewing prior authorization requests for medical services including elective admissions (Post-Acute and Acute), inpatient surgeries, outpatient surgeries, home health, and durable medical equipment. RN will prioritize expedited requests for medical necessity and efficiency in accordance with health plan coverage guidelines and CMS coverage determinations…

JOB SUMMARY The Contracting & Credentialing Specialist initiates, negotiates, and executes Medicare Advantage (MA) physician, hospital, and/or other provider contracts and agreements. The Contracting & Credentialing Specialist also obtains, reviews, and processes physician, facility, and ancillary initial & re-credentialing applications and supporting documentation to approve credentialing and…

Job Summary Under the direction of the Director of Care Management, the RN Care Manager is responsible for managing high risk, chronic illness members to promote effective education, self-management support, and timely healthcare delivery to achieve optimal quality and financial outcomes. The RN Care Manager will formulate and implement a care management plan that addresses the members…

JOB SUMMARY Under the direction of the Director of Quality and Senior Manager of Quality/Medicare Stars, the HEDIS Abstractor is responsible for year-round HEDIS medical record abstraction/education/strategy support in conjunction with the plans' Quality and Medicare Stars programs/initiatives. ESSENTIAL DUTIES AND RESPONSIBILITIES This position must be able to: Performs the Quality…

JOB SUMMARY The Intake Specialist will be responsible for entering requested authorization of health care services received via telephone, internet, and fax, sorting, and identifying incoming requests. The Intake Specialist will be responsible for following up with providers to obtain clinical information on UM requests. This role may also work with members on redirecting to in-network…