Serve as primary care manager for members with complex medical/behavioral needs Engage members telephonically to complete a comprehensive needs assessment, including assessment of medical, functional, cultural, and socioeconomic (SDOH) domains Develop and implement person centered care plans to address needs including management of chronic health conditions, health promot

Receive assigned provider inquiries and perform a code review on both professional and facility claims Make determinations on cases after a coding review is complete Review various edits on cases and complete audit of medical records received to ensure proper editing is applied Review medical charts electronically Abstract and code diagnosis and procedures from the medica

Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medicati

Small Business Sales (1 100) Create and drive strategies for top specialty producing agencies and Brokers Collaborate with Sales Management and/or Health Plan leadership regarding pipeline, persistency, market objectives and develop competitive strategies with specific Brokers/General Agents Work collaboratively with AE/RAC/SAE to support sales, product and process educat

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

Synthesize and forecast industry trends, customer needs, competitive threats, survey insights, member experience best practices and internal and competitive performance to design industry leading customer service and health plan improvement strategies Serve as a subject matter expert in CAHPS measure specifications, member pain points, survey strategy and business operati

Analyze, review, forecast and trend complex data Present analysis and recommendations for operational and business review/planning Support short and long term operational/strategic business activities through analysis Develop, recommend and implement business solutions through research and analysis of data and business processes This is a complex, fast paced, matrixed env

Make determinations of medical necessity/clinical appropriateness of treatment Assist in the development and implementation of clinical policy, guidelines and applications Regularly contact providers whose treatment determinations indicate a trend that varies with their peers and community Be knowledgeable on and apply all necessary regulatory requirements for assigned re

Make determinations of medical necessity/clinical appropriateness of treatment Assist in the development and implementation of clinical policy, guidelines and applications Regularly contact providers whose treatment determinations indicate a trend that varies with their peers and community Be knowledgeable on and apply all necessary regulatory requirements for assigned re

Proficient in review of medical records and the ability to identify pertinent information on which to base appropriate clinical decisions. Document relevant chronology of case review and provide rational for determination Plan, prioritizes, organizes and completes work to meet established objectives. Excellent verbal and written communication skills with internal and exte

Make determinations of medical necessity/clinical appropriateness of treatment Assist in the development and implementation of clinical policy, guidelines and applications Regularly contact providers whose treatment determinations indicate a trend that varies with their peers and community Be knowledgeable on and apply all necessary regulatory requirements for assigned re

Own the service experience of customers at the field level by working with the assigned team and other matrix partners as required to ensure issues are resolved promptly and accurately meeting the customer's expectations Develop and maintain strong relationships with internal partners throughout UHG to manage the customer service experience Fully accountable for supportin

Collaborate cross organizationally in the development, proposing and prioritization of customer solutions to reduce trend (programs, processes, benefit design, network, etc.) Works with business partners to ensure are aligned with successfully achieving savings targets Development and execution of cross functional strategies, projects and tactics which result in increment

Serve as primary contact as it relates to all enrollment tasks for assigned book of business, which include multiple group customers; maintain satisfied customers by providing superior service and practice attention to detail in various responsibilities. Answer member, provider, and group customer phone calls; adhering to department expectations for answering calls and pr

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