Telecommute Healthcare Advocate

Telecommute CDI Specialist (St. Louis, MO)

Compile and/or integrate information needed to complete reports and documents Prepare and/or format office documentation (e.g., letters; spreadsheets; reports) needed for various audiences (e.g.,clients; executives; internal business partners) Review prepared documents to ensure accuracy and quality, and revise as needed Post relevant documentation (e.g., meeting notes; P

In close coordination with the Medical Directors and Executive Leadership Team, will oversee the plan's strategic design, implementation, and evaluation of health equity efforts Works in collaboration with National teams including Population Health, Regulatory Adherence, etc. to identify population needs and opportunities, determine priorities, and plan action Inform deci

Utilize the Preferred One medical criteria and those of other regulatory bodies, (i.e. NCQA, DOH), the exempt and focused review programs, and the patient's benefit plan summary to perform medical necessity, level of service and appropriateness review Perform inpatient and outpatient pre admission, concurrent review and decision support based on medical necessity, appropr

Respond to and resolve, on the first call, customer service inquires and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility and claims, financial spending accounts and correspondence Help guide and educate customers about the fundamentals and benefits of consumer driven health care topics to select the best benefit plan o

Make outbound calls to assess members' current health status Identify gaps or barriers in treatment plans Provide patient education to assist with self management Interact with Medical Directors on challenging cases Coordinate care for members Make referrals to outside sources Coordinate services as needed (i.e., home health, DME, etc.) Educate members on disease processe

Chair a recurring workgroup that connects all Real Estate Delivery Integrated and Non Integrated Entity real estate leadership teams (all functions) together to facilitate best practice systems/processes/tools development Ownership of the RES operating model strategy and associated decision making tools, in close collaboration with the Corporate Service Mergers and Acquis

Evaluate and assess each request verifying eligibility and specific product Determine benefit level based on site of service Utilize written criteria to approve, pend or send the case to the medical director for review Send cases for pending process when appropriate Maintain at least 98% accuracy of clinical review case notes in Facets Maintain productivity standards and

Hybrid role available in office and virtually as scheduled to support ALTCS EPD members, families, providers, and internal and external stakeholders when needed Provide advocacy and system navigation of special health care needs of ALTCS EPD members services and supports To support resolution of concerns of ALTCS EPD members and their families Build partnerships with indi

Perform initial and ongoing reviews pertaining to primary role (PA, ICM, DCM, PACM), appropriately applying clinical criteria (InterQual, policies, National and Local Coverage Determinations) for approval and sending to Medical Directors if review is necessary for determining an adverse determination Collaborate with Medical Directors, clinical peers and Health Plan partn

Support primary team manager and director with all tasks related to appeal review Serve as a subject matter expert (SME) for benefit management and appeal cases review including job aids, processes, policies, regulations and clinical case review questions Assist with recruitment, onboarding, post training mentor for new hires and contract staff Lead meetings, presentation

Responsible for regulatory compliance oversight for the qualified and nonqualified plans of UnitedHealth Group and their affiliated entities (the "Plans"), which includes compliance testing, required plan notices, IRS/DOL reporting and research of benefits laws. Responsible for program compliance with company policies and controls, and with the laws, regulations and rules

Develop, lead and execute category management strategies, conduct sourcing / RFX events, manage suppliers and conduct financial analysis Primary responsibilities surround Pharmaceutical Draft, Review, and lead negotiations of third party supplier contracts, including Master Services Agreements (MSAs), Statements of Work (SOWs), Non Disclosure Agreements (NDAs) and amendme

Assess Medical Risk for the Company Review/Analyze Evidence of Insurability and determine appropriate course of action (e.g., request requirements, approve, rate, decline) Review/Analyze medical history of relevant populations (e.g., medical applications, APS, exams, claims history) to correctly and completely identify medical risk or potential increased risk of morbidity