Under the general direction of the Sr. Director IT, the SPM primary responsibilities will be the oversight of all NextGen PM and EMR installations throughout the RMG Network. Additional responsibilities include the day-to-day management of all employed physician offices and managing a variety of projects for varying operational functions with a clear beginning and end. The Senior Project Manager should relinquish responsibility for projects at their end (implementation date). An...
We are looking to hire a Provider Relations Network Manager to help support our Provider Relations Network Management team in Southern California in Orange County and surrounding areas. Position Summary: The Provider Relations Network Manager is responsible for general management of the provider network as assigned by the Director of Network Management as well as for supporting the Network Management Department in meeting the overall network growth and development goals....
The Project Manager is responsible for maintaining outpatient quality and financial budget and ensuring positive patient outcomes for Regal Medical Group. Accountable for overseeing management and optimization of Utilization Management activities related to outpatient care delivery programs. A Project manager is also expected to provide outpatient oversight. Essential Duties and Responsibilities include the following: Works collaboratively with outpatient leadership team working in concurrent review/Vital Care management/Prior Authorization Departments. Monitors and...
Outpatient Case Manager (RN/LVN) UHM-3755 {{jcity}}{{jstate}} Nursing Position Type: Full-time Position Summary: The Outpatient Case Manager is responsible for the assessment, treatment planning, intervention, monitoring, evaluation, and documentation on identified High Risk members. The Outpatient Case Manager will assess and develop a care plan in collaboration with the admitting, attending, and consulting physician, the member, and other health care practitioners. The goal of the Outpatient Care Manager is to effectively...
Ensure that all EZCap system eligibility data is current and accurate. Research and maintain systems and changes to existing eligibility in a timely manner. Essential Duties and Responsibilities include the following: Perform research and analysis of membership. Enter new member eligibility records into EZ Cap in accordance with established guidelines. Use activity analysis reports from the health plans to make changes to existing enrollees; i.e. benefit option changes, terminations, and...
Position Summary: The role of the Denial Nurse is to promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to denials. The Denial Nurse will review for appropriate care and setting and following guidelines/policies as it relates to denials. The Denial Nurse is responsible for processing denial letters for all affiliated groups, interpreting denial language provided by the...
Job Title: Nurse Practitioner (NP) - High-Risk Patient Care Position Summary We are seeking a dedicated Nurse Practitioner to play a vital role in reducing the readmission rates for high-risk patients in the Northwest Region. This position involves delivering clinical services in both home and clinic settings, specifically targeting patients with comorbid conditions such as Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD). The NP will take full...
Position Summary: This individual will be accountable for reducing the re-admission rate for a defined high-risk population in the Northwest Region. This accountability will include providing clinical services in the home and clinic settings which effectively reduce preventable re-admissions in the aforementioned population. This includes providing direct patient care, as well as triaging to appropriate coordination, social and behavioral health resources. The role includes the NP taking full responsibility for...
We are looking for Social Workers MSW/ LCSW to assist in our Medi-Cal SPD Medical Management program in San Diego and surrounding communities. Position Summary: Under the direction of Senior Manager, Social Services and collaborating closely with the Medi-Cal SPD Case Management Team, the Medi-Cal SPD Social Worker is responsible for assisting in the successful implementation of the newly launched Medi-Cal SPD (Seniors and Persons with Disabilities) Medical Management Program....
Position Summary: This individual will be accountable for reducing the re-admission rate for a defined high-risk population in the Northwest Region. This accountability will include providing clinical services in the home and clinic settings which effectively reduce preventable re-admissions in the aforementioned population. This includes providing direct patient care, as well as triaging to appropriate coordination, social and behavioral health resources. The role includes the NP taking full-responsibility for the...
Position Summary: The Case Manager Outpatient RN is responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified High Risk members. The Case Manager Outpatient RN will assess and develop a care plan in collaboration with the admitting, attending and consulting physician, the member and other health care practitioners. The goal of the Case Manager Outpatient RN is to effectively manage members on an outpatient basis to...
Responsibilities include but are not limited to data entry, maintenance, and reporting in, of and from the Contract Database (CDB); verification and processing of various forms used by Network Management, HR, Corporate and IS; and gathering provider information from a variety of sources. Essential Duties and Responsibilities include the following: Prepares, sends, and routes contracts per Data Management policies and procedures. Tracks provider contracts and related forms. Gathers and consolidates...
Area of Interest Utilization/Quality Management Position Type Full-time Job Description We are looking for experienced Inpatient Case Managers, After Hours /Weekends to join our team. They will follow-up appointments in the authorization notes and will communicate the same to the Vital Care Case Manager, the patient, and family members concerned. A follow-up post-discharge call will be made by the Inpatient Case Manager or the department’s designee within 24 hours of...
The Case Manager SNF LVN or RN is responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation for identified skilled or custodial level patients. The goal of the Inpatient SNF Case Manager is to effectively manage the patients' SNF stay to assure the right level of care is provided and that all the patients' medical, environmental and psychosocial needs are met, both during their stay, immediately upon discharge,...
This individual will be accountable for reducing the re-admission rate for a defined high-risk population in the Northwest Region. This accountability will include providing clinical services in the home and clinic settings which effectively reduce preventable re-admissions in the aforementioned population. This includes providing direct patient care, as well as triaging to appropriate coordination, social and behavioral health resources. The role includes the NP taking full-responsibility for the patient from...
Medical Group Accounts Receivable Specialist W97-3441 Administration Position Type: Full-time Position Summary: This position will provide day-to-day support as a Medical Group Accounts Receivable Specialist, focusing on accounts receivable follow-up and performing third-party insurance follow-up in the Central Billing Office. The personnel within this position are responsible for accomplishing assignments in accord with established policy, procedure, and production standards. This position must be equally capable of working independently as well...
Responsible for entering encounter data onto the claims adjudication system. In addition, and/or data enter encounter information onto the HMO system(s). Essential Duties and Responsibilities include the following: Responsible for the accurate and timely completion of tasks assigned and adhering to hourly/daily production standard in accordance with established policies and procedures. Process data entry of encounters with an accuracy rate not to fall below 97%. Identify issues that may influence...
The Coordinator, Outpatient is responsible for coordinating non-clinical tasks to support the delivery of care to members who meet case management criteria. Responsibilities include but are not limited to assisting in scheduling medical appointments, durable medical equipment, home health, eligibility/benefit verification, requesting medical records, data entry, and review of medical management reports. The Coordinator, Outpatient is accountable for outreaching members telephonically to introduce and invite them to Case Management. The...
Regal Medical Group is looking to hire a Director, HEDIS to join our team in Northridge, CA. Position Summary: The Director, HEDIS will provide direction and supervision to the HEDIS team and the management team of the HEDIS team. The Director will be responsible for developing and implementing quality measure initiatives. The goal of such initiatives is to drive superior quality measure performance scores for all lines of business (Senior...
Position Summary: Supervisor of Outpatient Case Management is responsible to directly support the Clinical Manager in overall management and oversight of Regal Outpatient Care Management Programs. The role will develop, implement and provide program oversight of Department projects and comply with the program contractual agreements. Supervisor develops strategies to implement and evaluate program effectiveness. Ensure that the Department is in compliance with Case Management Model of Care and Quality Regulatory...
To evaluate and determine the appropriate path and to assist in the expedited processing of all claims, special projects and escalated reconsiderations originating from various internal and external sources and to serve as the first level of telephonic and written response for such issues. Essential Duties and Responsibilities include the following: Maintain the workflow of all departmental projects. Provide reports and on-going updates to Claims management. Assist in the processing...
Under the general direction of the Medical Director, the Claims Review Nurse is responsible for reviewing medical bills and documentation using good judgment to make decisions regarding appropriate billing practices and communicating decisions to all stakeholders both internal and external. Position is responsible for remaining informed on billing and payment legislation and complying with all regulations related to review and payment. Claims Review Nurse will at all times maintain strict...
Area of Interest Utilization/Quality Management Position Type Full-time Work schedule: After hours 12 pm-12 am and Every other weekend 12 pm-12 am Position Summary: The After Hours Transfer Coordinator supports the process that manages the Afterhours Call Department. The goal for this position is to effectively support the Afterhours Call Services management process by assuring the right information is provided timely to the team. This includes ensuring that all necessary...
Area of Interest: Utilization/Quality Management Position Type: Full-time Job Description: Position Summary: The role of the Prior Auth Coordinator is to promptly, efficiently, and accurately execute all aspects of the referral process, facilitating the right care at the right time in the right setting. Responsibilities include processing requests from Access Express that are pended or reprocessed for approved or denied authorizations, checking eligibility and benefits on DME and home health...
This position will directly support the Vice President of Operations, Central Region providing coordination of administrative functions and supporting projects for the Clinical Operations department. Compiles data, performs data entry and runs reports. This position provides general assistance and support, interfaces with the executive team, Medical Directors, Management and all employees and will assist with special projects. This individual will provide data analysis, program evaluation activities, campus-specific program support, target...
Area of Interest Providers Position Type Full-time Job Description We are currently seeking an experienced Nurse Practitioner to join our Burbank, CA and Glendale, CA clinical team. This individual will provide in-home health care, assessments and patient care in assigned territory. Essential Duties and Responsibilities include the following: Visit members with complex care needs at home (5-7 members per day) Perform comprehensive health assessment which includes but is not limited...
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