Personify Health

Executive Assistant Job LocationsUS-NJ-Newark Job ID 2026-4694 Category People Type Full-Time Overview 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 Personify Health is seeking a highly organized, proactive, and detail-oriented Executive Assistant to support senior executive leaders within our organization. This role is responsible for managing priorities, coordinating logistics, and ensuring leaders are prepared and positioned to focus on strategic business objectives. The ideal candidate thrives in a fast-paced environment, anticipates needs before they arise, exercises sound judgment, and excels at building strong relationships across all levels of the organization. This individual will serve as a trusted partner to executive leadership while helping drive alignment, communication, and execution across key initiatives and stakeholders. This is a hybrid position based in Short Hills, New Jersey, requiring an on-site presence 1–2 days per week. Occasional travel may be required to support leadership meetings, company events, and business priorities. What You'll Do Own the Details that Drive Impact Manage complex executive calendars, coordinate domestic and international travel, and help prioritize competing demands to ensure leaders' time is aligned with the highest-impact work. Anticipate scheduling conflicts, proactively manage shifting priorities, and create efficiency in a dynamic environment. Deliver Excellence in Communication Help executive leaders stay organized and prepared by coordinating meeting logistics, organizing notes and materials, tracking action items, and supporting follow-up activities. Ensure information is communicated clearly and efficiently across stakeholders while maintaining a high level of professionalism, accuracy, and attention to detail. Drive Alignment and Follow-Through Plan and facilitate executive meetings, leadership team discussions, offsites, and company events. Prepare agendas, organize materials, document key takeaways, and track action items to ensure accountability and timely execution. Help leaders stay prepared for important discussions and decisions by organizing information and anticipating needs. Be a Trusted Connector Serve as a key liaison between executive leaders, employees, board members, private equity partners, external stakeholders, and other Executive Assistants across the organization. Coordinate meetings, communications, travel, and logistics across a broad network of stakeholders while fostering strong relationships and seamless collaboration. Handle sensitive and confidential matters with discretion, professionalism, and care. Keep Us Moving Forward Manage expense reports, travel arrangements, budget tracking, and administrative workflows while providing coordination and support across multiple functions. Anticipate needs during periods of travel, planning cycles, and high-volume activity to ensure continuity and momentum. Support Leadership Events and Business Operations Provide coordination and logistical support for executive meetings, leadership team gatherings, customer visits, board meetings, and company events. Partner with internal teams and external vendors to ensure seamless execution of both virtual and in-person experiences. What You'll Bring - 5+ years of experience supporting C-suite executives, Presidents, or senior business leaders in a fast-paced environment. - Demonstrated experience managing complex calendars, travel arrangements, and executive priorities. - Experience supporting multiple executives and balancing competing priorities. - Exceptional organizational skills with strong attention to detail and follow-through. - Strong written and verbal communication skills with a professional executive presence. - High emotional intelligence and the ability to build credibility and trust with senior leaders and stakeholders. - Proven ability to handle highly confidential information with discretion and sound judgment. - Strong problem-solving skills and the ability to anticipate needs before they arise. - Willingness to travel occasionally as needed to support executive and business priorities. Qualifications 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 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 plus 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.

Role Description Ready to (Please Note: All Candidates MUST possess an active Compact Licensure and be available to work within the Pacific Timezone) What You'll Actually Do - Telephonically coordinate wellness and disease management for members with chronic conditions, including but not limited to diabetes, asthma, COPD, CAD, CHF, atrial fibrillation, hypertension, and hyperlipidemia. - Proactively contact targeted members to promote health and restore optimal functioning by applying nationally recognized care guidelines and comparing current care with industry standards. - Review gaps in care and medical and pharmacy paid claims data to develop a comprehensive clinical profile; create individualized care plans and provide close follow-up for actively managed patients. - Collaborate with members to ensure assignment to a primary care provider; facilitate referrals to specialists as needed; assist with obtaining durable medical equipment and reviewing pricing for high-cost medications. - Support the Utilization Review process for assigned members in accordance with organizational and regulatory standards. - Assess member needs and initiate referrals to case management, prenatal, wellness programs, and external vendor services as appropriate. - Maintain complete, accurate, and timely documentation of case-managed members in designated systems; document all interventions and patient contacts while ensuring confidentiality and privacy of member records. - Track and monitor moderate and high-risk member populations and associated interventions to demonstrate improvements in overall health outcomes. - Meet established productivity, quality, and turnaround time standards on a daily, weekly, monthly basis. - Successfully participate in and pass external audits, including NCQA and URAC. - Maintain HIPAA compliance and confidentiality requirements in accordance with company policies and procedures. - Complete all required annual training within designated timeframes. KEY COMPETENCIES: - To be successful in a remote healthcare environment, individuals must demonstrate strong technical aptitude, communication skills, and the ability to work independently. Upon Hire, must have: - Basic computer literacy with the ability to navigate multiple systems simultaneously. - Ability to work on multiple screens with proficient typing skills. - Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Microsoft Outlook. - Strong verbal and written communication skills, including the ability to clearly explain complex or technical information and accurately interpret information received from others. - Ability to work independently, manage time effectively, utilize written resources to problem-solve and make informed decisions. - Foundational knowledge of medical claims processing and medical terminology, including ICD10, CPT, and HCPCS coding. Post-Training Expectations: - After completion of initial training and a structured ramp period (approximately three [3] months total), demonstrate proficiency in required systems and tools. - Ability to quickly adapt to additional systems or tools as job responsibilities evolve. Qualifications - Graduate of an accredited Registered Nurse (RN) program with a current, unrestricted Registered Nurse license issued in the United States. - The organization may require additional state licensure(s) to meet operational and business needs. - California, Washington and Oregon Licenses required after hire. - Prior experience in case management, wellness or disease management coordination, or an equivalent combination of education, clinical training, and relevant professional experience. - Demonstrated ability to apply clinical knowledge in a managed care, population health, or remote healthcare environment. - Bilingual English/Spanish preferred. - Willingness to travel. Requirements - Ability to perform the essential functions of the position safely and effectively, with or without reasonable accommodation, including meeting established qualitative and/or quantitative productivity standards. - Ability to maintain regular, punctual attendance in accordance with organizational policies. - Ability to remain seated for extended periods of time (approximately six [6] to eight [8] hours per workday). - Continuous use of a computer workstation, including frequent keyboarding and mouse usage, requiring repetitive hand and finger movements. - Ability to perform frequent neck twisting and occasional bending of the neck and waist as required to perform job duties. Benefits - Competitive base salary and benefits effective day one. - Comprehensive medical and dental through our own health solutions (yes, we use what we build). - Paid Time Off—rest and recharge time is non-negotiable. - Mental health support, retirement planning, and financial protection. - Professional development with clear career progression and learning budgets. - Mission-driven culture where diverse perspectives drive real impact on people's health. Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. This position offers a base salary range of $31-$38 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one. Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing. Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com. View all legitimate openings at personifyhealth.com/careers.

Role Description The Clinical Specialist, Quality Management & Training is a licensed clinical professional responsible for regulatory compliance, quality oversight, and workforce education across Utilization Management (UM), Case Management (CM), and Chronic Disease Management (CDM) programs. The role applies independent judgment and discretion to evaluate clinical systems, conduct internal and external audits, support accreditation readiness (e.g., NCQA/URAC), and implement quality and training improvements that strengthen documentation integrity, timeliness, and member protections. Essential Duties and Responsibilities - Ensure compliance with state, federal, and accreditation requirements (e.g., HIPAA, CMS, NCQA, URAC, ERISA, as applicable). - Conduct internal and external audits of UM/CM/CDM processes and documentation; prepare audit files, findings, and corrective action recommendations. - Identify quality and compliance risks and collaborate with cross-functional partners on mitigation and resolution. - Review and support SOPs and workflows to ensure regulatory alignment and operational clarity. - Support external audit readiness activities, including NCQA and URAC evidence preparation and maintenance. Training & Curriculum Delivery - Develop, maintain, and deliver role-based training curriculum aligned to compliance standards, quality goals, and operational workflows. - Conduct onboarding and orientation to prepare staff for assigned UM/CM/CDM functions. - Deliver training using multiple modalities (virtual, self-paced, and one-on-one coaching) tailored to adult learners. - Ensure training covers applicable processes such as case initiation and closure, documentation standards, high-dollar case monitoring, stop-loss notification, administrative support, customer service, and productivity expectations. Training Effectiveness & Corrective Action Support - Evaluate training effectiveness through feedback, observation, and performance data; identify improvement opportunities. - Maintain training records and competency documentation; track trends and escalate performance concerns as needed. - Conduct assigned quality audits to identify adherence gaps, documentation issues, and training needs. - Provide coaching and training support aligned to corrective action plans (CAPs); document outcomes and communicate status to leadership. Professional Standards & Productivity - Maintain current knowledge of regulatory, accreditation, and evidence-based practice standards. - Maintain HIPAA compliance and complete all required training within established timeframes. - Demonstrate proficiency in Microsoft Office and Smartsheet; meet productivity, quality, and turnaround time expectations. - Participate in required meetings and maintain professional, collaborative working relationships. Qualifications - UPON HIRE, must have: - Basic computer literacy. - The ability to work on multiple screens, and proficient typing skills. - Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook. - Ability to speak clearly and convey complex or technical information in a manner that others can understand. - Ability to work independently and utilize written resources to problem solve. - After training with our training department and 1.5 months ramp (3 months total), must have and be able to work in: - Teams on and off camera, SharePoint, Drives as needed, VPN, UM Web or Health Notes, El Dorado, Quick Links, GIAS, ADP, Confluence, Phone system with headset, Smartsheet. - Knowledge of medical claims and ICD-10, CPT, HCPCS coding. - Excellent verbal and written communication skills for upward and downward conversations. Requirements - Level I: - Active, unrestricted Registered Nurse (RN) license required; additional licensure may be required based on program scope. - Bachelor’s degree preferred. - 2–4 years of UM, CM, and/or DM/CDM experience required; managed care experience preferred. - Demonstrated ability to apply adult learning principles and deliver effective training. - Level II: - Bachelor’s or Master’s degree preferred. - 4–6 years of clinical quality assurance, compliance, or equivalent managed care experience. - CPHQ and/or CCM certification preferred. - 2–4 years leading, mentoring, and/or training staff preferred; advanced teaching/mentoring coursework preferred. - Senior: - Bachelor’s or Master’s degree preferred. - 4–6 years of managed care experience in UM, CM, and/or CDM. - Demonstrated experience in clinical quality, training, or accreditation readiness roles. - CPHQ, CCM, or other job-relevant certification required. Benefits - Competitive base salary and benefits effective day one. - Comprehensive medical and dental through our own health solutions. - Unlimited PTO—rest and recharge time is non-negotiable. - Mental health support, retirement planning, and financial protection. - Professional development with clear career progression and learning budgets. - Mission-driven culture where diverse perspectives drive real impact on people's health.

• Ready to lead health plan configuration and solution design, driving the full lifecycle of plan build and cross-functional execution across a complex TPA environment? • Lead and develop the teams overseeing Plan Configuration and Solution Architecture functions • Provide strategic oversight of plan build operations ensuring accuracy, efficiency, and on-time delivery • Drive continuous improvement across both functions, identifying process gaps and building solutions • Partner closely with Plan Configuration to ensure solution designs are buildable, scalable, and delivered on time • Support pre- and post-sale solutioning efforts, translating complex client requirements into viable plan designs • Own and manage the operational project portfolio for the TPA side of the business

• Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness • All inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity • Ensure proper referral to medical director for denial authorizations through independent review organizations (IRO) • Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care • Refer requests that fall outside of established guidelines to advance review or senior care consultants • Process appeals for non-certification of services; complete non-certification letters when appropriate • Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers • Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together program • Complete documentation for all reviews in Eldorado/Episodes; maintain confidentiality • Utilize MCG guidelines, medical policies, Medscape, and NCCN • Ability to meet productivity, quality, and turnaround times daily

Role Description The Medical Director relies on their medical background to review claims for medical necessity for prior authorization, continued stay review, and post service. The Medical Director can read, interpret, and apply medical policy, guidelines, and research to utilization review. The Medical Director has authority for issuing adverse determinations while performing medical necessity evaluation. - Has discussions with external physicians by phone to gather additional clinical information or discuss determinations regularly, requiring conflict resolution skills. - Includes an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment. - Keep the team informed of clinical updates through educational opportunities by developing educational materials for staff. - Work with the VP of Care management to establish work procedures and processes that support company and departmental standards, procedures, and strategic directives. - Excellent verbal and written communication skills. - Evidence of analytic and interpretation skills, with prior experience in quality management, utilization management, case management, discharge planning, and/or home health or post-acute services. - Knowledge of the managed care industry as it relates to commercial business. - Oversee negotiation and implementation of cost management strategies to affect quality outcomes. - Exercises independence in meeting departmental expectations and compliance timelines. - Ability to meet productivity, quality, and turnaround times daily. - Ability to pass external audits to include URAC and NCQA. - Maintain HIPAA compliance per company’s policy and procedures. - Maintain confidentiality and minimum requirement rules. - Complete all required yearly training per company’s expected period. Qualifications - MD or DO degree and 5+ years of direct clinical patient care experience post residency or fellowship, preferably including some experience in an inpatient environment. - Current and ongoing Board Certification in an approved ABMS Medical Specialty. - A current and unrestricted license in the state of California and willing to obtain additional license(s), if needed. (Optional) - No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements. - Minimum 5 years of Utilization Review or Hospital experience required. - Minimum 3 years of compliance-related experience preferred. - Managed Care experience preferred in utilization review and case management. Requirements - Ability to perform essential job functions safely and successfully with or without reasonable accommodation. - Ability to maintain regular, punctual attendance. - Ability to sit for 6-8 hours. - Constant use of computer keyboard and mouse; repetitive use of both hands. - Occasional to frequent twisting of neck; occasional bending of neck and at waist. Benefits - Part-time schedule designed around your availability and life priorities. - Access to learning and development opportunities alongside full-time colleagues. - Mentorship and skill-building that translates to career advancement. - Competitive hourly compensation that values your expertise. - Technology and equipment support to set you up for success.

Role Description The Care Management Manager of Education & Quality is responsible for the development, implementation, and ongoing oversight of regulatory compliance, quality assurance, and training programs across Care Management functions, including Utilization Management (UM), Case Management (CM), and Population Health/Disease Management. This role ensures clinical and non-clinical staff are equipped to meet state and federal regulatory requirements, accreditation standards (NCQA, URAC), and organizational expectations, while supporting operational excellence and continuous quality improvement. Essential Duties and Responsibilities - Compliance & Quality: - Support execution of established compliance, audit, and quality monitoring activities within Care Management programs. - Conduct routine file audits, training audits, and quality reviews using standardized tools. - Track, document, and report audit findings, corrective actions, and follow-up activities. - Ensure training, quality, and audit documentation meets regulatory and accreditation requirements. - Apply state, federal, NCQA, URAC, CMS, and ERISA requirements under supervision. - Training & Education: - Deliver training using established curricula for clinical and non-clinical staff. - Assist with onboarding education and ongoing refresher training. - Apply adult learning principles to support learner engagement and retention. - Maintain training records, attendance logs, and competency documentation. - Collaboration & Communication: - Collaborate with Care Management leaders, trainers, and compliance staff on implementation activities. - Escalate risks, gaps, or trends appropriately. Level II – Manager, Compliance & Training (Program & Advisory Focus) - Compliance & Quality: - Lead compliance monitoring activities across UM, CM, and population health programs. - Interpret regulatory and accreditation requirements and translate them into operational guidance, tools, and workflows. - Manage internal audits and support external audits, including preparation of evidence files and corrective action plans. - Analyze trends from audits, complaints, and quality data to identify systemic risk and improvement opportunities. - Serve as a subject matter expert for Care Management regulatory requirements. - Training & Education: - Design, implement, and evaluate formal training programs using multiple modalities (virtual, self-paced, live, 1:1). - Conduct training needs assessments and gap analyses. - Measure training effectiveness and adjust curricula based on outcomes and quality findings. - Leadership & Partnership: - Provide consultation to operational leaders on compliance, quality, and training strategies. - Participate in Quality Improvement Committee (QIC) activities as assigned. - Mentor staff and contribute to skill development within the training/compliance team. Senior Level – Senior Manager, Care Management Compliance & Training (Strategic Leadership Focus) - Provide enterprise-level leadership for Care Management compliance, quality, and education strategy. - Ensure Care Management programs remain continuously audit-ready. - Lead regulatory interpretation, impact assessment, and organizational response planning. - Oversee development and annual evaluation of the Quality Management Program components related to Care Management. - Represent Care Management in enterprise compliance initiatives and accreditation engagements. Training & Workforce Strategy - Establish long-term training and competency frameworks aligned with organizational growth, automation, and regulatory change. - Drive innovation in training delivery, measurement, and scalability. - Ensure training programs support quality outcomes, staff readiness, and member experience. Leadership & Influence - Lead and develop the compliance and training team, including performance management and succession planning. - Advise senior leaders, Medical Directors, and executives on compliance risk, quality performance, and readiness. - Foster a culture of continuous learning, accountability, and improvement. Qualifications - Basic computer literacy. - The ability to work on multiple screens, and proficient typing skills. - Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook. - Ability to speak clearly and convey complex or technical information in a manner that others can understand. - Ability to work independently and utilize written resources to problem solve. - Knowledge of medical claims and ICD-10, CPT, HCPCS coding. - Excellent verbal and written communication skills for upward and downward conversations. Requirements - Level I: - Active, unrestricted Registered Nurse (RN) license required. - Minimum 2–4 years of experience in managed care, Care Management, UM, or quality/compliance support. - Experience delivering or supporting staff training preferred. - Level II: - Active, unrestricted RN license required. - Bachelor’s degree preferred. - Minimum 4–6 years of experience in Care Management compliance, quality, UM/CM, or training. - Demonstrated experience leading audits, training programs, or quality initiatives. - Relevant certifications preferred (CPHQ, CCM, etc.). - Senior Level: - Active, unrestricted RN license required. - Bachelor’s degree required; advanced degree preferred. - 6+ years of progressive leadership experience in managed care compliance, quality, and training. - Deep experience with NCQA/URAC surveys, CMS alignment, and multi-state regulatory oversight. - Proven leadership and strategic program development experience. Benefits - Competitive base salary and benefits effective day one. - Comprehensive medical and dental through our own health solutions. - Unlimited PTO—rest and recharge time is non-negotiable. - Mental health support, retirement planning, and financial protection. - Professional development with clear career progression and learning budgets. - Mission-driven culture where diverse perspectives drive real impact on people's health.

• Broker distribution and development • Interpreting and qualifying Requests for Proposals (RFP’s) • Experienced user of Salesforce.com • Ability to cold call prospects and brokers • Ability to present wellness solutions with a virtual format and the use of power point • Help to manage, implement, deliver, evaluate and improve all workplace wellness programs and resources • Ability to be consultative in all things well-being • Become expert in all ancillary wellness services that are offered and have the ability to provide strategic direction for prospects and current clients • Able to generate new leads via broker and direct to end user sales channels • Build and sustain positive relationships with the entire Wellness IQ staff • Ability to present and sell to consultants or employer groups of 50-1500 employees • Interact with staff, management and vendors to ensure operational efficiency and effectiveness • Frequent travel required

Role Description Provide professional assessment and review for the medical necessity of treatment requests and plans. - Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness. - Review inpatient hospital stay including mental health, substance abuse, skilled nursing, and rehabilitation for medical necessity. - Conduct post claim or post service reviews. - Cross train and provide cross coverage as needed. - Work to the top of the RN license and ensure proper referral to medical director for denial authorizations through independent review organizations (IRO). - Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care. - Refer requests that fall outside of established guidelines to advance review or senior care consultants. - Process appeals for non-certification of services and complete non-certification letters when appropriate. - Review plan document for benefit determinations and attempt to redirect providers and patients to PPO providers. - Identify and refer potential cases to case management, wellness, chronic disease, and Nurturing Together programs. - Complete documentation for all reviews in appropriate documentation software. - Utilize guidelines in appropriate hierarchy, including MCG guidelines, internal medical policies, group specific policies, and NCCN. - Meet productivity, quality, and turnaround times daily. - Pass external audits to include URAC and NCQA. - Maintain HIPAA compliance per company’s policy and procedures. - Maintain confidentiality and minimum requirement rules. - Complete all required yearly training per company’s expected time limit. - Complete and pass all annual testing including IRRA at 90% or higher. Qualifications - Current RN license in the United States or U.S. territory. - Associate’s degree or diploma (Nursing program) required. - 1+ year clinical experience required. Requirements - Ability to perform the essential job functions safely and successfully with or without reasonable accommodation. - Ability to maintain regular, punctual attendance. - Ability to sit for 6-8 hours. - Constant use of computer keyboard and mouse; repetitive use of both hands. - Occasional to frequent twisting of neck; occasional bending of neck and at waist. - Must be able to remain in a stationary position 50% of the time. - Occasionally move about inside the office to access office machinery, filing cabinets, and meeting facilities. - Constantly operate a computer and other office productivity machinery, such as copy machine, computer printer, calculator, etc. - Frequently position self to maintain files in file cabinets. - Frequently move boxes or equipment weighing up to 25 pounds. - Must communicate information and ideas so others understand. - Must be able to observe details at close range. Benefits - Competitive base salary and benefits effective day one. - Comprehensive medical and dental through our own health solutions. - Paid Time Off—rest and recharge time is non-negotiable. - Mental health support, retirement planning, and financial protection. - Professional development with clear career progression and learning budgets. - Mission-driven culture where diverse perspectives drive real impact on people's health. Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Company Description Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive.

• Provide telephonic case management between providers, patients and caregivers to help ensure cost-effective, high-quality healthcare for health insurance plan participants • Contact patient and complete a thorough assessment, including physical, psychosocial, emotional, spiritual, environmental, and financial needs • Use claims processing tools to review and research paid claim data to develop a clinical picture of a member’s health and identify for participation in appropriate programs • Develop treatment plan for standard and catastrophic cases in collaboration with the patient, caregivers or family, community resources and multi-disciplinary healthcare providers that include obtainable short- and long-term goals • Monitor interventions and evaluate the effectiveness of the treatment plan in a timely manner; report measurable outcomes that record effectiveness of interventions • Initiate and maintain contact with the patient/family, provider, employer, and multidisciplinary team as needed throughout the continuum of care • Advocate for the patient by facilitating the delivery of quality patient care • Negotiate and implement cost management strategies to affect quality outcomes and reflect this data in monthly case management reviews and cost avoidance reports • Establish and maintain working relationships with healthcare providers, client/group, and patients to provide emotional support, guidance and information • Evaluate and make referrals for wellness programs • Maintain complete and detailed documentation of case managed patients in Eldorado and UM Web; maintain site specific files ensuring confidentiality; prepare reports and updates at 30-day intervals for high-risk cases and 90 days interval for low-risk cases ensuring confidentiality according to Company policy and HIPAA • Perform Utilization Review for assigned members • Serve as mentors to LVNs and provide guidance on complicated cases as it relates to clinical issue