Clinical Services Utilization Supervisor – Hamilton & Surrounding Counties Company: CareStar, Inc. Location: Hamilton, Ohio (and surrounding areas) Job Type: Full Time | Remote with Field Visits Industry: Healthcare / Social Services / Case Management About the Opportunity at CareStar Founded in 1988 in Cincinnati, Ohio, CareStar, Inc. is a recognized leader in long-term care case management and population health. With a mission to Improve Communities by Improving Lives, we proudly serve individuals across Ohio through compassionate, high-quality care coordination. We are currently seeking a Clinical Services Utilization Supervisor to join our Assessments program. This is a meaningful opportunity for professionals who are passionate about helping others live healthier, more independent lives. As a Clinical Services Utilization Supervisor, you’ll work directly with individuals to assess their needs, develop personalized care plans, and connect them with essential services and supports. You’ll be part of a mission-driven team that values your expertise, supports your growth, and empowers you to make a real difference in your community. Key Responsibilities - Monitor service delivery and ensure compliance with program guidelines - Serve as the lead advocate and care coordinator for each participant - Educates, guides, oversees, and counsel’s clinical employees in the performance of task related to Due Process and Prior Authorizations. - Formulates training material for Due Process and Prior Authorizations and conducts training for Clinical Team as necessary. - Provides guidance to staff related to applicable rule reference and disenrollment determinations; identifies problematic cases and refers to the Clinical Supervisor and/or Clinical Manager as appropriate. - Maintains/updates knowledge of Medicare, Medicaid, insurance and program and State specific waivers; maintains knowledge of the Americans with Disabilities Act. - Understands current and future state and other program information to assist with business objectives; establishes rapport with State and other programs employees. - Prepares appeal summaries and exhibits list for processing to be presented at hearing; represents CareStar at appeal hearings; be available to provide testimony at appeal hearings. - Reviews hearing rights for appropriateness and submits them for processing to ensure compliance with the State administrative code. - Reviews hearing decisions and coordinates compliance with the determination, prepares and submits compliance forms per requirements, including issuance of hearing rights. - Provides support to staff in assessing need for prior authorization and assures that determination is supported by medical necessity; reviews prior authorizations prior to submissions to state specific Department of Medicaid for completeness and compliance with the state specific administrative code and CareStar requirements. - Adhere to the CareStar Rule in performance of job responsibilities. - Understand and comply with CareStar Policies and Procedures. - Maintain confidentiality as related to patient information. Any disclosures of confidential information made unlawfully outside the proper course of duty will be treated as a serious disciplinary offense. - Follow the Acceptable Use Policy while using any information systems owned or controlled by CareStar, Inc. Minimum Qualifications - Bachelor’s degree in Social Work, Counseling, Psychology, Nursing, or a related field and at least three (3) years of either pediatric, Developmental Disabilities or mental health experience within the last ten (10) years is desirable. - Licensed Social Worker (LSW), Licensed Independent Social Worker (LISW) or Registered Nurse (RN) - Minimum 3 year of experience in home and community-based services (within the last 10 years) - Experience working with individuals with chronic conditions or severe and persistent mental illness - Strong knowledge of Medicaid, behavioral health systems, and local community resources Why Join CareStar? - Remote flexibility with meaningful community engagement - Competitive salary based on experience and education - Comprehensive benefits: Medical, dental, vision, life insurance - 401(k) with a generous company match - Paid time off + 10 paid holidays - Employee Stock Ownership Plan (ESOP) – become a part-owner in the company - Supportive, mission-driven culture focused on improving lives Apply Today Ready to make a difference? Visit https://www.carestar.com/about-carestar/careers/ to apply and learn more about joining our team.

Imagine360 is seeking a Transplant Case Manager, RN to join the team! The Transplant Case Manager, RN is responsible to providing case management for individuals under the group health plans administered by Imagine360 by utilizing nursing education, clinical and professional experience. The Registered Nurse will practice within the scope of nursing practice while performing assessments, coordinating care, planning, monitoring, evaluating and determining outcomes. Position Location: 100% remote Responsibilities include but are not limited to: - Identify, collect, process, and manage data to perform the Case Management process by utilization Imagine360 approved clinical guidelines and following Medical Management Policy and Procedures - Completes clinical assessments per P&P to identify and deliver indicated medical service coordination. - Manage the transplant cases, cases that may lead toward organ transplant, and complex disease cases. - Utilize clinical knowledge, expertise, and educational resources to provide verbal and/or written educational resources to members regarding diagnosis, procedures and/or treatment. - Assess the need for and collaborate with community resources for members in case management. - Uses assigned software accurately to document to complete and document all steps of review of medical necessity and case management process, including time slips. - Facilitate the Patient Satisfaction Surveys - Assess for cost savings and document the cost saving in assigned software - Appropriately refer complex cases to Supervisor, Case Management, or designee - Performs essential activities of case management while maintaining members' confidentiality, safety, advocacy, adherence to ethical, legal and accreditation and regulatory standards. - Performs assessments of each member to identify CM needs. - Consistently exercises discretion and judgment to analyze, interpret, make deductions, and then decide what actions are necessary based on the varying facts and circumstances of each individual case. - Determines measurable goals utilizing motivational interviewing and behavior change model and coaches' clients while monitoring self-care practices. - Utilizes industry standard tools to guide individuals with chronic/ongoing health conditions through coaching, assessments, listening, and other techniques as appropriate. - Executes activities or interventions to achieve the goals in the plan. - Organizes, integrates, and modifies the resources needed to reach the goals in the plan. - Monitors all information from all relevant sources in the plan and its activities and services to determine the plan's effectiveness. - At repeated intervals, evaluates to determine ultimate effectiveness of plan and modifies plan appropriately to meet the goals. - Research medical procedures, treatments, and coding when necessary. - Measures the outcomes of interventions. - Adheres to practicing the care management core components throughout the continuum of care: - Case Management Concepts - Case Management Principles and Strategies - Psychosocial and Support Systems - Healthcare Management and Delivery - Healthcare Reimbursement - Vocational Concepts and Strategies. - Customer Service - Acts as a role model in demonstrating the core values in customer service delivery. - Provides timely and thorough follow up with, internal and external customers. - Appropriately escalates difficult issues up the chain of command. - Quality Assurance - Serves on committees, work groups, and/or process improvement teams, as assigned, to assist in improving quality/customer satisfaction. - Recognizes and alerts appropriate supervisor of trends within their scope of responsibility that fall outside of quality parameters. - Performs self-quality monitoring to develop and execute plans to meet established goals. - Provides ongoing feedback to help optimize quality performance. - Collaborates with others and cross-departmentally to improve or streamline procedures. - Develops new or improves current internal processes to improve quality. - Attend and participate in team meetings, trainings, and other job specific events as required. - Communicates (in compliance with HIPAA) with brokers, vendors, Relationship Managers, HR representatives and stop loss as needed. - Communicates professionally and effectively. - Adhere to established internal regulations regarding Department of Labor, HIPAA, ERISA and department and company policies and Procedures. - Participate in the Quality Management Program via collecting and adhering to performance metrics per Case Management Policy - Complete HIPAA Training Annually. - Perform all tasks in accordance with HIPAA/PHI guidelines. - Appropriately escalate difficult issues. - Complete duties in accordance with scope of licensure and certifications held or requested. - Perform other duties and projects, as assigned. Areas of Responsibility Scope of Practice: - In addition to performing standard duties, the Registered Nurse is involved in clinical decision-making and patient education. The scope of practice includes, but is not limited to: - Evaluating clinical data - Assessment and evaluation of the acquired clinical date to assess for appropriateness of treatment based on Imagine360 clinical guidelines, - Coordination of treatment plans, interventions, and outcome measurement - Rationale for the effects of medication and treatments - Provide patient education and educational resources. - Accurately report: - Administration of medication and treatments - Client response - Contact with other health care team members. - Respect the client's right to privacy by protecting confidential information. - Promote and participate in education and counseling to a participant based on health needs. - Clarify any treatment that is believed to be inaccurate, non-efficacious, or contraindicated by consulting with appropriate practitioner. - The Transplant Case Manager will have knowledge and practice the core components of Case Management that include: - Case Management Concepts - Principles of Practice - HealthCare Management & Delivery - Healthcare Reimbursement - Psychosocial Aspects of Care - Rehabilitation - Professional Development & Advancement - Quality and Outcomes Evaluation and Measurement - Ethical, Legal and Practice Standards Required Experience/Education: - Graduate of Accredited School of Nursing, college or university required - Minimum of one year experience in Utilization Management, Case Management, or transferable skills. - Minimum of three years Transplant experience - Intermediate knowledge and skills using Microsoft Office including Word, Excel, and PowerPoint software; Internet software; Database software. Skills and Abilities: - Ability to work independently in a home office environment. - Computer skills which include proficiency in Microsoft Outlook, Word, Excel, and PowerPoint, as well as navigation utilizing the internet. - Ability to resolve problems independently and demonstrate ability to multi-task. - Strong written, oral, and telephonic communication skills. - Strong presentation skills. - Ability to demonstrate a commitment to building new skills and fostering a positive work environment. - Demonstrated organizational skills, problem-solving, analytical skills, and detail oriented. - Demonstrated ability to prioritize workloads, multi-task, and manage priorities to meet deadlines. - Ability to maintain the confidentiality of protected health information in compliance with HIPAA regulations. License and Certifications: - Must maintain active, current, and unrestricted Registered Nurse license and CEU's as required by the State Board of Nursing. Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization. - Must be a Certified Case Manager or eligible to sit for the Certified Case Management Exam within 3 years of starting employment with i360. What can Imagine360 offer you? - Multiple Health plan options - Company paid employee premiums for disability and life insurance - Parental Leave Policy - 20 days PTO to start / 10 Paid Holidays - Tuition reimbursement - 401k Company contribution - Company paid Short & Long term Disability plus Life Insurance - Professional development initiatives / continuous learning opportunities - Opportunities to participate in and support the company's diversity and inclusion initiatives Want to see our latest job opportunities? Follow us on LinkedIn Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions. Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status. **RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/CV's submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation**

The Manager, Clinical Appeals & Grievances is responsible for leading, operating, and advising a dynamic and fast-paced Clinical Appeals & Grievances team. This role works closely with multiple leaders in the organization to identify priority focus areas for Appeals & Grievances, to standardize and optimize processes, and to communicate performance to multiple stakeholders. In tandem with these efforts, this individual will oversee internal and external production teams to ensure consistent production, high quality and to maintain compliance on all levels. This role will remain flexible while utilizing strategic thinking and creativity to address challenges in alignment with long term growth and profitability goals of Healthfirst. Duties and Responsibilities: - Manages a team of specialists, with responsibility for goal and productivity management, coaching and counseling, performance management and other leadership responsibilities as assigned - Provides oversight in case research and provides advice as needed - Understands HF’s internal health plans’ policies and procedures to frame decisions - Interprets regulations to provide guidance to specialists on a daily basis - Ensures the timely resolution of cases and makes critical decisions - Focuses on clinical criteria for expedited cases - Helps standardize and optimize how Appeals and Grievances are routed - Determine best practices and strategically deploy approaches to meet production, compliance and quality targets - Works with leadership to establish and implement departmental goals, establish monthly goal review process and implement a plan of action for identified gaps - Provides guidance in the preparation of case preparation for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case - Has oversight in case preparation for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process - Assists in leading the AOR / WOL Outreach team in coordination with the supervisor - Works with Providers and DSE on educating providers in how to submit Appeals timely and accurately. - Maintains delegated vendor relationship and ensure vendor performance and compliance measures are met - Institutes and manages working relationships within various operational areas to identify and execute overall process improvements - Diagnoses and understands operational challenges in addition to skill gaps in order to provide leadership and management to the Appeals & Grievances team - Identifies trends and recommends solutions for improvement. - Drives the development of innovative tools, systems, and processes to assist in overall handling of Appeals & Grievances functions - Maintains knowledge of industry trends, best practices and protocols and collaborating with other parts of the enterprise to ensure general consistencies and enhancements - Additional duties as assigned Minimum Qualifications: - Bachelor's degree from an accredited institution or equivalent work experience - RN - Experience with utilization management or appeals and grievance processing and compliance - Working experience in a fast-paced environment overseeing multiple priorities, tasks and/or teams - Proven track record of exercising independent thinking, ability to problem solve, understand process flows and correlating platforms to recommend and implement solutions - Experience preparing and delivering written and verbal information to multiple types of audiences - Demonstrated ability to build and foster effective relationships Preferred Qualifications: - Experience in clinical practice with a focus in appeals & grievances, claims processing, utilization review or utilization management/case management. - Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines - Extensive experience in healthcare appeals - MBA or master's degree from an accredited institution with focus in training & development, education, business, or healthcare administration - Management experience in an operational department within the healthcare industry focused on clinical leadership - Leadership experience in a focus area of operational excellence or audit - Experience developing strategy and processes for a department or function - Experience managing vendors as an extension of a core team. Familiar with creating accountable ownership of a vendor team WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC. Know Your Rights All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: - Greater New York City Area (NY, NJ, CT residents): $103,400 - $149,430 - All Other Locations (within approved locations): $88,700 - $131,920 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

Job Description Job Summary The Specialist, Member & Community Interventions implements new and existing clinical quality member intervention initiatives including all lines of business (Medicare, Marketplace, Medicaid) Executes health plan’s member and community quality focused interventions and programs in accordance with prescribed program standards, conducts data collection, monitors intervention activity including key performance measurement activities, reports intervention outcomes, and supports continuous improvement of intervention processes and outcomes. Job Duties - Implements evidence-based and data-informed key member intervention strategies, which may include initiating and managing member and/or community interventions (e.g., removing barriers to care) and other federal and state-required quality activities - Monitors and ensures that key member intervention activities are completed on time and accurately to present results to key departmental management and other Molina departments as needed - Writes narrative reports to interpret regulatory specifications, explain programs and results of programs, and document findings and limitations of department interventions - Creates, manages, and/or compiles the required documentation to maintain critical program milestones, deadlines, and/or deliverables - Participates in quality improvement activities, meetings, and discussions with and between other departments within the organization - Supports provision of high-quality clinical care and services by facilitating/building strategic relationships with community-based organizations - Evaluates project/program activities and results to identify opportunities for improvement - Surfaces to the Manager and Director any gaps in processes that may require remediation - Demonstrates flexibility when it comes to changes and maintains a positive outlook - Other tasks, duties, projects, and programs as assigned - This position may require same-day out-of-office travel 0 - 80% of the time, depending upon location - This position may require multiple days out-of-town overnight travel on occasion, depending upon location Job Qualifications REQUIRED QUALIFICATIONS: - Associate’s degree or equivalent combination of education and work experience - 1-3 years’ experience in healthcare with 1-year experience in health plan quality member interventions, managed care, or equivalent experience - Demonstrated solid business writing experience - Operational knowledge and experience with Excel and Visio (flow chart equivalent) - Excellent problem-solving skills PREFERRED QUALIFICATIONS: - Bachelor’s Degree in preferred field: Nursing, Social Work, Clinical Quality, Public Health, or Healthcare Administration - 1 year of experience in Medicare and in Medicaid managed care - Certified Professional in Health Quality (CPHQ) - Nursing License (RN may be preferred for specific roles) - Certified HEDIS Compliance Auditor (CHCA) To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing Molina Healthcare offers a competitive benefits and compensation package Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V