Utilize advanced clinical skills to engage and motivate Consumers via a recovery, health and wellness oriented approach Assist consumers and their families/caregivers with connections to appropriate psychiatric, medical, and psychosocial referrals and services Identify and remove barriers to procurement, delivery, participation in and success of services Provide supportiv

Design, implement and maintain .NET applications within all phases of the Software Development Life Cycle (SDLC) Develop, test, implement and maintain application software working with established processes Communicate effectively with other developers and quality assurance analysts. Establish, refine and integrate development and test environment tools and software as ne

Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations Document clinical review findings, actions, and outcomes in accordance with policies, and regulatory and accreditation requirements Engage with requesting providers as needed in peer to peer discussions Be knowledgeable in

Make outbound calls and receive inbound calls to assess members' current health status Identify gaps or barriers in treatment plans Provide patient education to assist with self management Make referrals to internal and external sources as outlined by member's benefit plan design Provide a complete continuum of quality care through close communication with members via on

Work closely with cross functional teams and leadership to build consensus and successfully lead and support strategic planning and delivery for a variety of Optum strategic initiatives, programs and events Collaborate with internal stakeholders, including C suite executives and matrixed business partners, to understand program and event requirements and goals in order to

Conduct coverage review based on individual member plan documents, and national and proprietary coverage review guidelines, render coverage determinations, and discuss with requesting providers as needed in peer to peer telephone calls Use clinical knowledge in the application and interpretation of medical policy and benefit document language in the process of clinical co

Responsible for handling inbound calls, from providers and members in a call center environment Conduct initial clinical assessments and determine appropriate levels of care, based on medical necessity Explain and administer benefits according to plan descriptions for all levels of care (OP, IOP,PHP,RTC,IP) Ability to quickly assess and meet time sensitive deadlines withi

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Research issues and develop customers specific solutions Provide in person Member services to both M&R and DSNP members with their languages at retail store, services including but not limited to Benefits Policies, Procedures, and protocols (pre auth, enrollments, renew rewards, etc.) Claim / billing issues (follow up calls with resolution to identified issues in timely m

Program Administration Collaborates with key university departments (Registrar, Bursar, IT Services, University Communications and Marketing, Health Services. Student Life, etc.) to ensure processes pertaining to the SHIP are as smooth and seamless as possible throughout the insurance plan year. Regularly assesses and facilitates the implementation of the annual online st

Assist audit management or audit lead in the execution of internal audits including audit planning, detailing control procedures, and the related testing and reporting in accordance with professional and departmental standards including financial (i.e. Sarbanes Oxley testing) and operational projects Prepare clear, accurate and complete workpapers in accordance with depar

Provide members with tools and educational support needed to navigate the health care system and manage their health concerns effectively and cost efficiently Assist members with adverse determinations, including the appeal process Teach members how to navigate UMR internet based wellness tools and resources Outreach to membership providing pre admission counseling to mem

Determine that the case is assigned to the appropriate team for review (e.g., Medicare, Medicaid, Commercial) Validate that cases/requests for services require additional research Identify and utilize appropriate resources to conduct non clinical research (e.g., benefit documents, evidence of coverage, state/federal mandates, online resources) Prioritize cases based on ap

Answer incoming phone calls from prospective members, identify the type of assistance and information the customer needs with the goal to convert caller to a qualified lead and sale Follow up with members on questions or to review current or new products and services Navigate multiple computer systems to document member information while maintaining active listening and e

Answer incoming phone calls from prospective members, identify the type of assistance and information the customer needs with the goal to convert caller to a qualified lead and sale Follow up with members on questions or to review current or new products and services Navigate multiple computer systems to document member information while maintaining active listening and e