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Provides care management services to more than 2 million members in South Carolina and nationally. Administers complex, high touch concierge case management for members identified into specialized programs such as high risk maternity, NICU, ESRD, Palliative Care Behavioral Health. Identifies risks and provides outreach services to facilitate the coordination of healthcare services and gap closure.
Posted 25 days ago
Responsible for the supervision and maintenance of the daily functions of the following areas Utilization Review/Review Nurses, Case Management, Medical Review, Health/Disease Management, Quality Management, and/or Appeals, to include departmental staff and specialty programs. Responsible for all data collection for specialty programs and ensures appropriate levels of healthcare services are provi
Posted 29 days ago
Care management interventions focus on improving care coordination and reducing the fragmentation of the services the recipients of care often experience, especially when multiple health care providers and different care settings are involved. Taken collectively, case management interventions are intended to enhance client safety, well being, and quality of life. These interventions carefully cons
Posted 29 days ago
Coordinates the quality control program for the medical review area. Researches the Center for Medicare and Medicaid services (CMS) changes. Trains new staff and provides continuing education to clinical staff. Description 30% Reviews medical review decisions for accuracy and to ensure CMS instructions have been applied correctly. 25% Develops/implements the quality control program used as an in
Posted 29 days ago
Provides reinsurance support for new and renewal business, underwriting, claims audit/record keeping and/or other functions. May perform calculations and process general accounting requests for billing or payments, and/or check the status of claims and process policy changes. Provides customer service to clients and partners. Runs reports as needed. Description 55% Processes mail, email and faxe
Posted 1 month ago
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