Perform individual case review for appeals and grievances for various health plan and insurance products, which may include PPO, ASO, HMO, MAPD, and PDP. The appeals are in response to adverse determinations for medical services related to benefit design and coverage and the application of clinical criteria of medical policies Perform Department of Insurance/Department of

Serve as primary care manager for high medical risks / needs members with comorbid behavioral health needs Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic (SDoH) needs Develop and implement individualized, person centered care plans inclusiv

Assess, plan, and implement care strategies that are individualized by the member and directed toward the most appropriate, lease restrictive level of care Utilize both company and community based resources to establish a safe and effective case management plan for members Collaborate with patient, family, and healthcare providers Identify and initiate referrals for socia

Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medicati

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Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medicati

Leadership (Measured through performance metrics, Colleague Reviews) Overall local market health plan clinical operations for all products including achievement of annual clinical, quality/affordability and utilization management goals Local market SME for all clinical/medical management programs and contractual requirements Lead, coach/develop, trains (in conjunction wit

Act as liaison between Developers, QA, Business and Systems Analysts and project management groups Coordinate with individuals and teams to gather requirements within the OCIO IT organization Understand and communicate SMART Team capabilities and offerings to external parties Build relationships with internal and external UHG partners Assist in creation of effective inter

Positions in this function are responsible for providing expertise or general support to teams in reviewing, researching, investigating, negotiating, and resolving all types of appeals and grievances Communicates with appropriate parties regarding appeals and grievance issues, implications, and decisions Analyzes and identifies trends for all appeals and grievances May re

Implement and maintain data bases necessary to complete standard reportable event reports and analysis within agreed upon deadlines surrounding the HCBS LTSS population Complete ad hoc reports and analysis as requested by State partner or internal LTSS leadership Routinely analyze results of reportable event submissions, substantiations, and CAPs to identify trends such a

Develop, lead, and execute category management plans, competitive events, deal analysis, and complex negotiations for IT Software/Hardware and Services Support the end to end procurement process from sourcing through contracting, including pipeline management, in accordance with category strategy Review, develop, redline, and negotiate complex third party vendor contracts

Conduct financial and network pricing modeling, analysis and reporting Perform unit cost and contract valuation analysis in support of network contracting negotiations and unit cost management strategies Lead projects to completion by contributing to database creation, statistical modeling and financial reports Concisely summarize and communicate the results of complex an

Functional role is responsible for utilization management of LTSS determinations, oversight on outpatient service requests from a reporting perspective and understanding the criteria for inpatient reviews, including concurrent inpatient reviews Leverage experience and understanding of disease pathology (e.g., conditions, normal course of care for a condition) to review ch

Build and maintain solid relationships with key brokers and others as necessary within the assigned territory Develops action plans and strategies to optimize Medicare sales Partner with the Community Developer (CD) and Sales Director (SD) to identify and develop relationships with individuals and organizations that influence the buying behavior of our target consumer (e.

As part of a multi disciplinary care coordination team Addresses the total patient, inclusive of medical, psychosocial, behavioral, cultural, and spiritual needs Involves the individual patient and caregiver, as appropriate, in decision making Facilitates communication and coordination among members of the care team Provides patient care to include patient assessment prio