HireOps

• This position is responsible for conducting medical management and health education programs for customers on government health care programs. • Accountabilities include gathering, analyzing and providing date for regulatory reports. • This position will represent the company to members.

• This position is responsible for conducting medical management and health education programs for customers on government health care programs. • Accountabilities include gathering, analyzing and providing data for regulatory reports. • This position will represent the company to members.

• RN working in the insurance or managed care industry using medically accepted criteria to validate the medical necessity and appropriateness of the treatment plan. • Performing accurate and timely medical review of claims suspended for medical necessity, contract interpretation, pricing; • Initiating and/or responding to correspondence from providers or members concerning medical determinations. • Knowledge of accreditation, i.e. URAC, NCQA standards and health insurance legislation. • Awareness of claims processes and claims processing systems. • PC proficiency to include Microsoft Word and Excel and health insurance databases. • Verbal and written communication skills with the ability to communicate to physicians, members and providers and compose and explain document findings. • Organizational skills and prioritization skills.

• This position is responsible for conducting medical management and health education programs for customers on government health care programs. • Accountabilities include gathering, analyzing and providing data for regulatory reports. • This position will represent the company to members.

• Performing initial, concurrent review activities • Discharge care coordination for determining efficiency, effectiveness and quality of medical/surgical services • Serving as liaison between providers and medical and network management divisions • Collecting clinical and non-clinical data • Verifying eligibility • Determining benefit levels in accordance to contract guidelines • Providing information regarding utilization management requirements and operational procedures to members, providers and facilities

• Responsible for discharge care coordination, episodic case management and pre-admission/post-discharge counseling for an acute condition. • Establish relationships with the member through the immediate post discharge follow-up period or until all short-term care needs are met. • Provide education/local resource information and encourage member (self) education. • Determine case complexity and refer to other internal departments as needed. • Consult with physicians, coordinators, and facility discharge planners to determine other resources and appropriate disposition of such cases. • Perform additional ongoing functions to support the member in the transition of care process including more than one of the following: a. Consult with physicians, providers, members, and other resources, as appropriate, to assess, plan, facilitate implementation, coordinate, monitor and evaluate options and services required to meet an individual’s acute health needs, using communication and available resources to promote quality health outcomes. • Personalize outreach/engagement based upon attitudes/behaviors/risk assessment. Outreach to provider to coordinate the member’s care or to notify of risks/new conditions. • Reconcile, educate and monitor adherence to medication safety. • Reinforce provider post-operative instructions for care, diet, activity level etc. • Address barriers to keeping follow-up appointments with appropriate provider and assistance with appointment scheduling. • Assistance finding a primary or specialist provider, a Blue Distinction Center, or any needed coordination with Customer Service. • Provide onsite face to face intervention in select cases. • Education and recommendations to resolve conditions and risks, and support for behavior change/ self-management. • Collaborate with the provider and member when appropriate to develop alternate plans of care if needed. • Assist members/providers to navigate the health care system. • Assess cases for quality-of-care issues and refer cases to the QA/QI department for review and follow up. • Perform Transition of Care services for all assigned lines of business. • Practice within the scope of licensure. • Participate as preceptor for orientation of new employees. • Maintain licensure and maintain and enhance knowledge for designated area of licensure and regulatory standards by attending seminars, training sessions, etc. • Communicate and interact effectively and professionally with co-workers, management, customers, etc. • Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies. • Maintain complete confidentiality of company business. • Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.