American Specialty Health Incorporated is seeking a Clinical Review Support Specialist to join our Contracts department. This position will support medical necessity review determinations of services requested by Physical Therapy practitioners through provider communication, education, and clinical coordination. Salary Range American Specialty Health complies with state and federal wage and hour laws and compensation depends upon candidate’s qualifications, education, skill set, years of experience, and internal equity. $48,000 to $60,000 Full-Time Annual Salary Range. Remote Worker Considerations: Remote Worker Guidelines: This position will be trained remotely and must be able to work from home (WFH) in a designated work area with company-provided technology equipment. This WFH position requires you have a stable connection to your Internet Service Provider with the ability to participate by video in online meetings over a reliable and consistent network. The internet connection must have a consistent 50 down/10 up Mbps minimum internet speed. 100 down/20 up is recommended to support higher quality video meetings. Responsibilities - Support of medical necessity review determinations. - Perform outreach calls to practitioners and clinical practices for network and non-network therapy practitioners. - Determine and obtain appropriate clinical assessment for submitted diagnosis codes. - Clarify provider requests, providing education on ASH’s submission process, forms, and available resources. - Facilitate clinical review through coordination and distribution of reviews among Clinical Quality Evaluators. - Collaborate with senior management and various departments regarding clinical program, policies, and protocol development and implementation. - Participate in Clinical Quality Administration and Clinical Quality Evaluation workgroups. - Promote a productive Team environment. - Participate in clinical article review activities as assigned. - Provide interdepartmental Support to Medical Necessity Administration department as necessary for performance of assigned tasks. - Work independently, receiving minimal guidance and supervision. Qualifications - Professional degree as Physical Therapy Assistant from accredited college or university required. Additional post-graduate degree in same or related field a plus. - A current, unrestricted license to practice in their health care specialty. Employees must maintain a current, unrestricted license to practice and must be in good standing with all judicial and governing bodies (Required). - Minimum of 5 years of clinical experience. Specific experience with care coordination or leadership preferred. - Understanding of therapy evidence-based guidelines and best practices required. - Working knowledge of managed therapy services is a plus. - Advanced training or certification in any specialty areas of Physical Therapy, health care or quality management, case management, performance improvement, data analysis, and quality initiatives also preferred. - Ability to communicate evidence-based criteria and approved guidelines. Ability to independently resolve problems or issues related to ASH processes using good judgment or to escalate problems or issues to supervisor(s) as appropriate. - Use of computer systems in business application including, but not limited to: Outlook, MS Word, IHIS, ASHCore. - Ability and willingness to serve as a resource for practitioners to educate them how to operate within ASH programs and systems most effectively and efficiently. Core Competencies - Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships. - Ability to display excellent customer service to meet the needs and expectations of both internal and external customers. - Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment. - Ability to effectively organize, prioritize, multi-task, and manage time. - Demonstrated accuracy and productivity in a changing environment with constant interruptions. - Demonstrated ability to analyze information, problems, issues, situations, and procedures to develop effective solutions. - Ability to exercise strict confidentiality in all matters. Mobility Primarily sedentary, able to sit for long periods of time, able to travel by automobile and air.?? Physical Requirements Ability to speak, see and hear other personnel and/or objects. Ability to communicate both in oral and written form. Ability to travel within the facility. Capable of using a telephone and computer keyboard. Ability to lift up to 10 lbs. Environmental Conditions Work-from-home (WFH) environment. American Specialty Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to sex (including pregnancy, childbirth, related medical conditions, breastfeeding, and reproductive health decision-making), gender, gender identity, gender expression, race, color, religion (including religious dress and grooming practices), creed, national origin, citizenship, ancestry, physical or mental disability, legally-protected medical condition, marital status, age, sexual orientation, genetic information, military or veteran status, political affiliation, or any other basis protected by applicable local, federal or state law. Please view Equal Employment Opportunity Posters provided by OFCCP here. If you are a qualified individual with a disability or a disabled veteran, you have the right to request an accommodation if you are unable or limited in your ability to use or access our career center as a result of your disability. To request an accommodation, contact our Human Resources Department at (800) 848-3555 x6702. ASH will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the Company’s legal duty to furnish information. #LI-Remote #Physician #PhysicalTherapy #Clinical #Medical #MedicalNecessity

The Care Manager plans and manages behavioral and/or physical care with members and their beneficiaries and works with clinicians and health care team members. The Care Manager facilitates care and medical attention and addresses identified member needs across the continuum of care. The Care Manager is responsible for applying care management principles when engaging members and addressing coordination of the member’s health care services. The Care Manager is assigned to a specific product line such as FIDA, CompleteCare, SNP, Medicaid/Medicare, PHSP, HARP, etc. *Depending on one’s residence and line of business, the Care Manager may be expected to make home, nursing home, and other related sites visits around downstate New York. Duties/Responsibilities: - Advocates, informs, and educates beneficiaries on services, self-management techniques, and health benefits. - Conducts assessments to identify barriers and opportunities for intervention. - Develops care plans that align with the physician’s treatment plans and recommends interventions that align with proposed goals. - Generates referrals to providers, community-based resources, and appropriate services and other resources to assist in goal achievement. - Collaborates with provider doctors, social workers, discharge planners, and community based service providers to coordinate care accordingly. - Coordinates and facilitates with the multi-disciplinary health care team as necessary in order to ensure care plan goals are achieved and maximize member outcomes. - Assists in identifying opportunities for alternative care options based on member needs and assessments. - Evaluates service authorizations to ensure alignment and execution of the member’s care and physician treatment plan. - Contributes to corporate goals through ongoing execution of member care plans and member goal achievement. - Documents all encounters with providers, members, and vendors in the appropriate system in accordance with internal and established documentation procedures; follows up as needed; and updates care plans based on member needs, as appropriate. - Occasional overtime as necessary. - Additional duties as assigned. 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): $83,100 - $120,360 - All Other Locations (within approved locations): $73,400 - $108,160 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 Profile Summary A vital role of the CMO Administration team, the Medical Peer Reviewer plays a critical role in consulting on medical necessity in the context of utilization management and ensuring adherence to internal Healthfirst and external regulations. Duties/Responsibilities: ·The Medical Peer Reviewer will assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations. ·The Medical Peer Reviewer will render determinations in the format and within timeframes to follow Regulatory and Operational policies. · The Medical Peer Reviewer will: ·Maintain productivity standards. · Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases/caseload from multiple lines of businesses ·Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members/internal medical departments as needed ·Complete mandatory Company compliance training and training in new systems and software. ·Enter each day’s hours worked in Workday, on the same day. ·Perform other duties as assigned ·Responsibilities may be adjusted based on changing needs of the organization. Weekday Requirements: ·The Medical reviewer requires 25 hours a week of coverage. The configuration of the 25 hours may change with the business needs, with a minimum of 3 days a week, 2 days at 8 hours and one day at 9 hours. Maximum of 5 days a week of coverage · The Medical Reviewer will take 8 hours off during the week after being primary coverage for a weekend, usually the following Friday. ·Each Medical Reviewer will cover one legal holiday /year and will be compensated Holiday pay and straight hours worked ·The Medical Reviewer is eligible for Paid Time Off (PTO) and is required to plan and schedule time off with their direct supervisor following the Company policy. Weekend Requirements: · Each Medical Reviewer is required to be primary coverage one weekend a month · Each Medical Reviewer is required to be available as back up, if needed, one weekend a month · Dental Reviewers have a fixed schedule Minimum Qualifications: Licensed M.D. or D.O. or D.M.D. or D.D.S. Board Certified in a specialty recognized by the American Board of Medical Specialties Preferred Qualifications: ·Board Certified in Internal Medicine , Family Practice, OBGYN, Emergency Medicine ·Previous, relevant experience in utilization management and clinical practice ·Knowledge of Medicare, Medicaid, and MLTC plans ·Time management, critical thinking, communication, and problem-solving skills ·Knowledge of UM/QM case philosophies and reporting requirements to state and federal agencies ·Knowledge of member satisfaction/incident management and regulations ·Knowledge of quality improvement methodologies Compliance & Regulatory Responsibilities: Ensures compliance to internal Healthfirst and external regulations. · Licensed M.D. or D.O. or D.M.D. or D.D.S. · Annual Compliance and other training as assigned, may include but not limited to hardware, software, and system training upgrades · Annual Inter-Rater Reliability (IRR) Testing · Complies with the Healthfirst Conflict of Interest Policy for Professionals 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): $122,907 - $188,020 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.

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. **This role requires approximately 50% travel to support members in the Kansas City KS metropolitan area. Applicants have the flexibility to work remotely from their home the remaining time. We provide all required equipment and reimburse for mileage at the current IRS rate. The schedule is Monday - Friday, 8am - 5pm.** Position Purpose: Assists in developing, assessing, and coordinating holistic care management activities to enable quality, cost-effective healthcare outcomes. May develop or assist with developing personalized service care plans/service plans for long-term care members and educates members and their families/caregivers on services and benefits available to meet member needs. - Evaluates the needs of the member, the resources available, and recommends and/or facilitates the plan for the best outcome - Assists with developing ongoing long-term care plans/service plans and works to identify providers, specialist, and/or community resources needed for long-term care - Coordinates as appropriate between the member and/or family/caregivers and the care provider team to ensure identified services are accessible to members - Provides resource support to members and their families/caregivers for various needs (e.g. employment, housing, participant direction, independent living, justice, foster care) based on service assessment and plans - Monitors care plans/service plans, member status and outcomes, as appropriate, and provides recommendations to care plan/service plan based on identified member needs - Interacts with long-term care healthcare providers and partners as appropriate to ensure member needs are met - Collects, documents, and maintains long-term care member information and care management activities to ensure compliance with current state, federal, and third-party payer regulators - May perform home and/or other site visits to assess member’s needs and collaborate with healthcare providers and partners - Provides and/or facilitates education to long-term care members and their families/caregivers on procedures, healthcare provider instructions, service options, referrals, and healthcare benefits - Provides feedback to leadership on opportunities to improve and enhance quality of care and service delivery for long-term care members in a cost-effective manner - Performs other duties as assigned. - Complies with all policies and standards. Education/Experience: Requires a Bachelor's degree and 2 – 4 years of related experience. Or equivalent experience acquired through accomplishments of applicable knowledge, duties, scope and skill reflective of the level of this position. Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act