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Customer Service Representative I (HNGSS) (1155725) Position Purpose The Customer Service Representative (CSR) functions as a primary resource in handling TRICARE customer contacts via telephone, ranging from routine to complex. The CSR provides clear and concise education concerning the TRICARE medical benefits and government policies and procedures. The CSR assists beneficiaries with benefit inf
Posted 3 days ago
Supervisor, Quality Improvement (1158029) Position Purpose Oversee the day to day quality review function, ensuring accurate and timely review of department processes to ensure compliance with applicable state, federal and accrediting body requirements. Provide supervision for appeals and grievance, quality of care/service; provider redeterminations and other applicable department activities inclu
Posted 4 days ago
Quality Improvement Specialist I (1155096) Position Purpose Support the data management and quality improvement initiatives for assigned functional areas Assist with the development and coordination of all core health services data reports Support the development of quality improvement performance audit function processes and tools Assist in designing, running, managing, and data review process fo
Posted 4 days ago
Contract Implementation Analyst (1152550) Position Purpose Perform day to day duties and testing of contract implementation, including UAT to ensure that systems accurately reflect a contract's negotiated terms. Perform audits of provider setup within the provider information system to ensure accurate contract implementation and subsequent claims processing Review and price contract related pends
Posted 4 days ago
Prior Authorization Nurse I (1151097) Position Purpose Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests. Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward request
Posted 5 days ago
Medicare Sales Representative (Pittsburgh, PA) (1152332) Position Purpose Our Medicare SalesRepresentatives for our Allwell Medicare plans ensurethat Allwell is the choice for Medicare eligible individualsin their assigned territory. They use a consultative sales approach toencourage enrollment in an Allwell product by presentingproduct options to prospective members, while understanding and compl
Posted 5 days ago
Perform onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Direc
Posted 5 days ago
Serve as the claims payment expert for the Plan and as a liaison between the plan, claims, and various departments to effectively identify and resolve claims issues. Act as the subject matter expert for other Claims Liaisons. Analyze trends in claims processing issues and identify work process solutions Lead meetings with various departments to assign claim project priorities and monitor days in s
Posted 6 days ago
Contract Coordinator (1157696) Position Purpose Create contracts and manage the contracting process for new business opportunities, prepare contract status and metric reporting, identify gaps and risks in contracting process, and assist with work assignments and training for temporary staff. Create contracts and manage contracting process utilizing the Emptoris Contract Management System to ensure
Posted 6 days ago
Supervisor, Service Coordination (1156857) Position Purpose Supervise the day to day operations of the service coordination function. Communicate with departmental and plan administrative staff to facilitate daily department functions. Provide direct supervision of service coordination staff, including hiring, training, evaluation, development and performance management Monitor and direct workflow
Posted 10 days ago
Supervisor, Service Coordination (1156858) Position Purpose Supervise the day to day operations of the service coordination function. Communicate with departmental and plan administrative staff to facilitate daily department functions. Provide direct supervision of service coordination staff, including hiring, training, evaluation, development and performance management Monitor and direct workflow
Posted 10 days ago
Supervisor, Service Coordination (1156852) Position Purpose Supervise the day to day operations of the service coordination function. Communicate with departmental and plan administrative staff to facilitate daily department functions. Provide direct supervision of service coordination staff, including hiring, training, evaluation, development and performance management Monitor and direct workflow
Posted 10 days ago
Customer Service Representative II (HNGSS) (1153730) Position Purpose This is the advanced level of Customer Service Representative, responsible for handling customer service questions and issues. Associates at this level handle escalated issues that require greater product and service knowledge, and a higher level of customer service skill. The Customer Service Representative takes calls and proc
Posted 11 days ago
Supervisor, Program Coordination (1154408) Position Purpose Perform collaborative duties for the development and implementation of all Coordinated Care programs (OB/NICU, Asthma, Diabetes, ER, General/Catastrophic); Provide support and supervision to ensure quality and continuity of services delivered to Members, Providers and staff. Develop and oversee aspects of coordinated care program activiti
Posted 13 days ago
Senior Prior Authorization Nurse (1154476) Position Purpose Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests. Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward re
Posted 13 days ago
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