As a part of the care management team, the Care Coordinator will be the primary care manager for a panel of members with chronic and complex health care needs. This position will provide support to the broader team with clinical and non-clinical activities to support a person-centered approach to care coordination. Care coordination activities will focus on supporting member’s medical, behavioral, and socioeconomic needs to promote appropriate utilization of services and improved quality of care. This is a fast-paced working environment that requires the ability to multitask with attention to detail and excellent organizational skills. If you are located in Ada or Canyon County, you will have the flexibility to work remotely as you take on some tough challenges. Serve as the primary care manager for dual eligible members Engage people face-to-face and/or telephonically to complete a comprehensive needs assessment or wellness assessment (as appropriate), including assessment of medical, behavioral, functional, cultural, and social drivers of health (SDoH) Develop and implement individualized, person-centered care plans inclusive of goals, opportunities and interventions aligned with a person’s readiness to change to support the best health and quality of life outcomes by meeting them where they are in their health journey Partner and collaborate with the internal care team, providers, and community resources/partners to implement care plans and remove obstacles so the member can successfully stay in or return to the community (when appropriate) Assist members with obtaining necessary HCBS supports and services Provide referral and linkage as appropriate and accepted by the individual being served (may include internal consult opportunities such as Housing Navigator, Pharmacy Team, Peer Specialist, etc. or community-based provider referrals such as PCP, specialists, medication assisted therapy referrals, etc.) Support proactive discharge planning and manage/coordinate care transition following ER visit, inpatient or Skilled Nursing Facility Provide education and coaching to support member self-management of care needs and lifestyle changes to promote health Advocate for people and families, as needed, to ensure that the member’s needs and choices are fully represented and supported by the health care team Support Provider and Facility nonclinical questions (credentialing, claims, etc.) connecting them to the correct Health Plan and/or UHC resources

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Utilization Management (UM) Coordinator supports the coordination, processing, and administrative functions of the utilization review process. This role ensures timely and appropriate review of healthcare services in accordance with established guidelines and regulatory requirements, working closely with UM nurses, physicians, and other healthcare professionals. - Receive, review, and process incoming requests for authorization of medical services. - Coordinate with providers, members, and internal clinical staff to gather necessary documentation for utilization reviews. - Enter authorization requests and updates into the utilization management system accurately and promptly. - Track and monitor pending authorizations to ensure timely processing and communication of decisions. - Collaborate with nurses and physicians to facilitate medical necessity reviews and ensure compliance with clinical guidelines. - Provide notification of determination (approvals or denials) to providers and members in accordance with regulatory timeframes. - Maintain accurate and organized records to ensure compliance with accreditation and regulatory bodies (e.g., NCQA, CMS, Health Plans). - Assist in audits and quality improvement activities as needed. - Serve as a liaison between internal departments, providers, and external vendors. - Ensure compliance with HIPAA and confidentiality standards at all times. Qualifications - High School Diploma or equivalent required; Associate’s degree or healthcare certification preferred. - 2+ years of experience in health plan environment; experience in utilization management or case management support strongly preferred. - Capacity to interpret health plan benefit decisions. - Bilingual preferred (English/Spanish). - Certification as a Medical Assistant preferred. Requirements - Strong knowledge of medical terminology and healthcare authorization processes. - Proficient in Microsoft Office Suite and medical management systems (e.g., MCG, or similar UM platforms). - Excellent communication, organization, and customer service skills. - Ability to work independently and manage multiple priorities in a fast-paced environment. Benefits - Health benefits - Life and disability benefits - 401(k) savings plan with match - Paid Time Off - Paid holidays

A dedicated and experienced Nurse Practitioner (NP) or Physician Assistant (PA) to provide high-quality remote care during night shifts for acute and post-acute care facilities. The ideal candidate will triage, evaluate, and manage patient care, ensuring continuity of care and reducing unnecessary emergency department visits. This is a fully remote role that requires clinical expertise, strong communication skills, and the ability to work independently during nighttime hours. Respond promptly to after-hours calls from acute and post-acute care facilities. Provide comprehensive assessments via telecommunication to determine the appropriate level of care. Manage acute conditions, chronic disease exacerbations, and other patient needs, adhering to evidence-based practices. Collaborate with facility staff, including nurses and on-site providers, to ensure optimal patient care. Document encounters accurately and efficiently to ensure smooth handoff with dayshift team. Prescribe medications and treatments within the scope of practice and in compliance with state regulations. Facilitate referrals or escalate care to on-site providers or emergency services when necessary. Ensure all clinical decisions comply with facility protocols and regulatory requirements. Participate in quality improvement initiatives as needed.

Optum CA is seeking an Outpatient Case Manager to join our team in San Diego, CA. As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone. In this role, you will: Review contracted Medical Group’s authorization requests for medical necessity Determine which requests need Medical Director review Obtain sufficient medical documentation for informed decisions Process all requests within established timeframes Document all steps of the process in the authorization system Utilize industry standard denial language for denial letters The work schedule will be Monday through Thursday 6:30am-5pm. Primary Responsibilities: Review contracted Medical Group’s referral requests for medical necessity Consider appropriateness of the setting, place of service, health plan’s benefits, and criteria of the requested services Document process in authorization notes Refer all medical necessity denials to the physician for review Process denials within established timeframes Document denial reasons in the authorization system utilizing industry standard denial letter language Outline alternative services available Review requests within established timeframes for urgent, routine, and retro requests to maintain compliance with legislative and accreditation standards Obtain additional information for review of appeals Coordinate with health plan to meet timeframes for expedited appeals You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.