Pediatric Managed Care Coordinator Ii Jobs

Offers education to member about Case Management services and available resources in coordination with Case Managers.

Participates in physician/case management/concurrent review rounds as needed.

Creates episode for referral to Case Management.

3-5 years of related managed care experience required

Verifies benefit details with the health plans.

Working knowledge of medical terminology

Promote and assist the development of education materials for patients and families in support of clinical practice of the medical staff.

Provide education pertinent to patient care for hospital personnel and other health care providers.

Participate in other educational events to maintain current expertise and provide training to other support staff within the office.

Work experience: Prefer two years experience working in a physician's office.

BLS certification maintained. Must be American Heart Association

Assess and evaluate the patient population during initial phone conversation.

Knowledge of standards in managed care credentialing practiced, health plan credentialing requirements, statistics, data collection, analysis and data presentation

Excellent interpersonal communication, organizational and problem-solving skills.

Responsible for leading the activities associated with coordinating, monitoring and maintaining the credentialing and re-credentialing process.

Proficient in computer applications (e.g. Windows, Microsoft Office, Internet browsers, medical staff/credentialing software databases, etc.)

Assist with the management of pediatric patient care and act as a staff resource as needed during the day.

A minimum of two years current nursing experience.

Employee annual raises when meeting or exceeding job expectations

Employer-paid Health Insurance (medical, dental and vision): 100% for employee and 80% for dependents.

17 days PTO per year

Retirement Plan with 6% match

Knowledge of all regulatory requirements and internal processes to ensure that all maintenance and contractual documents are managed to expectations

Minimum of one (1) year of experience in a managed care or healthcare organization or contract development and review is required

Prior experience with provider documents and provider data entry is highly preferred

Perform any other job duties as requested

Intermediate computer skills including Microsoft Word, Excel and Outlook

Critical listening and thinking skills

Specific education and years and type of experience may be required based upon state law and contract requirements.

Uses appropriate screening criteria knowledge and clinical judgment to assess member needs.

For MMP, requires Community Health Worker certification to be obtained within one year of employment.

QMHP Certification of MA/MS in Social Work, Counseling, or a related behavioral health field preferred.

Conducts assessments to identify individual needs and develops care plan to address objectives and goals as identified during assessment.

Monitors and evaluates effectiveness of care plan and modifies plan as needed.

Preferred Work Experience: 7 years-healthcare program management.

Job title: Managed CareCoordinator II (Remote)

Preferred Licenses and Certificates: Case Manager certification, clinical certification in specialty area.

Note: 1st week of onsite training then remote.

Preferred Education: Bachelor's degree- Nursing.

5% Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.

Strong knowledge of the principles of managed care, pharmacy benefit management, pharmaceutical reimbursement, and pharmaceutical utilization

Experience and/or training in statistics, computer science, data management, or similar fields preferred

Provide data visualization that supports leadership in oversight, management, and strategic planning

Competitive compensation and benefits package

Bachelor's degree or equivalent experience in a related field required, Master's degree preferred

Two years of business analysis project coordination related experience required

General Knowledge, Skills & Abilities

Updates Sales and Account Management on Direction of Care rules and changes throughout the year

Bachelor’s Degree in Business or related field or the equivalent combination of education, training, and work experience.

Requires working knowledge of managed care services in the workers’ comp industry including bill review, PPOs, and direction of care rules.

Opportunities to work from home

Tuition Reimbursement Program including certifications

NCQA (National Committee for Quality Assurance) Certification is a plus.

Must have a Bachelors or LPN License.

Valid WA State Driver’s License and proof of liability insurance.

Paid-time-off starting at 24 days per year + 10 paid Holidays.

Sea Mar is a mandatory COVID-19 and flu vaccine organization

Sea Mar is an Equal Opportunity Employer

Primary liaison between marketing liaisons, facilities admissions and MCO Case Management for new referrals and readmissions.

Communicates and maintains effective working relationships with marketing teams, facility contacts, and case management team as relates to referral process.

Able to hold facilities accountable to adhere to the process for referrals to case management of MCO cases.

Assistant to Case Management Consultant - Obtaining Auth, communication with communities, and communication with insurance companies.

Experience working in a skilled nursing facility

Performs review of referral requests for completeness of information and determines when ready to move to a case manager for preauthorization.

Bachelor's degree of Science with 5 years of related supervisory/ management experience, or the equivalent in education and experience required.

Excellent organization, interpersonal, oral and writing skills required.

Prior experience with budgetary preparation and systems development required.

Leads the health care team of each assigned section in all aspects of the daily operations of the individual section(s).

Continually assesses the sections needs and changes support staff roles and levels.

Facilitates a multidisciplinary approach to problem identification and resolution with other departments/sections at D-H.

Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans.

Promotes enrollment in care management programs and/or health and disease management programs.

Seven years healthcare program management.

Thorough knowledge/understanding of claims/coding analysis, requirements, and processes.

Case Manager certification, clinical certification in specialty.

Continuing education funds for additional certifications and certification renewal

Updates Sales and Account Management on Direction of Care rules and changes throughout the year

Bachelor’s Degree in Business or related field or the equivalent combination of education, training, and work experience.

Requires working knowledge of managed care services in the workers’ comp industry including bill review, PPOs, and direction of care rules.

Opportunities to work from home

Tuition Reimbursement Program including certifications

Manage provider network data extracts and workflows related to MCO participation

100% paid medical premiums for our full-time employees

The longer you stay, the more vacation you’ll accrue!

Longevity Pay (Monthly payments after two years of service)

Build your future with our awesome retirement/pension plan!

Free financial and legal counseling

Free mental health counseling services

Minimum of 2 years previous work experience in a health care setting required.

Medical terminology, ICD, CPT and/or coding experience preferred.

Strongly prefer medical assistant, home health aide, nursing assistant or other similar health care para-professional training or certification.

Excellent interpersonal and verbal communication skills and the ability to write clear and concise reports.

Attention to detail and confidentiality with strong organizational skills.

Proficient PC skills in a Windows based environment including word processing, spreadsheets, and database programs.

Experience with patients on the phone, answering questions and routing calls as needed

Experience with nuances of members requests, and able to effectively prioritize them

Experience working in a high growth environment and comfortability jumping into new processes

Understanding of the healthcare ecosystem: past experience working with patients preferred

Manage inbound members messages, ensuring proper prioritization across various types of messages

Manage coordination of care across the healthcare system

Equivalent experience will be accepted in lieu of the required degree or diploma.

2 years recent relevant experience.

This position is work from home eligible.

*Occasional on-site meetings and office practice site visits*

Pay Range: $39.59 - $59.38 / hour

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Experience with project management tools preferred

Effective organizational and time management skills with the ability to prioritize tasks

Three (3) years of experience and expertise in complex project management

Experience in an international setting and with project management methodologies preferred

Utilizing project management tools to effectively coordinate priority work activities, track timelines, tasks, and deliverables, and provide regular progress reporting

Demonstrated problem solving skills, with the ability to analyze and synthesize information