Partner with UMR operations and Vendor partner, own the service experience of customers at the field level by working with the UMR Operations Team and other matrix partners as required to ensure issues are resolved promptly and accurately meeting the customers' expectations Develop and maintain solid relationship with internal partners in the UMR Service Team to manage cu

Coordinate Test Environment booking by different application teams Coordinate Test Environment upgrades and data refreshes with infrastructure implementation teams Required experience of PHI/PII data requirements Hold weekly review meeting with test environment stakeholder and share future bookings calendar. Required experience of managing technical implementations in non

Perform individual case review for appeals and grievances for various health plan and insurance products, which may include PPO, ASO, HMO, MAPD, and PDP. The appeals are in response to adverse determinations for medical services related to benefit design and coverage and the application of clinical criteria of medical policies Perform Department of Insurance/Department of

Serve as primary care manager for high medical risks / needs members with comorbid behavioral health needs Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic (SDoH) needs Develop and implement individualized, person centered care plans inclusiv

Assess, plan, and implement care strategies that are individualized by the member and directed toward the most appropriate, lease restrictive level of care Utilize both company and community based resources to establish a safe and effective case management plan for members Collaborate with patient, family, and healthcare providers Identify and initiate referrals for socia

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

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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

Leadership (Measured through performance metrics, Colleague Reviews) Overall local market health plan clinical operations for all products including achievement of annual clinical, quality/affordability and utilization management goals Local market SME for all clinical/medical management programs and contractual requirements Lead, coach/develop, trains (in conjunction wit

Implement and maintain data bases necessary to complete standard reportable event reports and analysis within agreed upon deadlines surrounding the HCBS LTSS population Complete ad hoc reports and analysis as requested by State partner or internal LTSS leadership Routinely analyze results of reportable event submissions, substantiations, and CAPs to identify trends such a

Develop, lead, and execute category management plans, competitive events, deal analysis, and complex negotiations for IT Software/Hardware and Services Support the end to end procurement process from sourcing through contracting, including pipeline management, in accordance with category strategy Review, develop, redline, and negotiate complex third party vendor contracts

Conduct financial and network pricing modeling, analysis and reporting Perform unit cost and contract valuation analysis in support of network contracting negotiations and unit cost management strategies Lead projects to completion by contributing to database creation, statistical modeling and financial reports Concisely summarize and communicate the results of complex an

Functional role is responsible for utilization management of LTSS determinations, oversight on outpatient service requests from a reporting perspective and understanding the criteria for inpatient reviews, including concurrent inpatient reviews Leverage experience and understanding of disease pathology (e.g., conditions, normal course of care for a condition) to review ch

Build and maintain solid relationships with key brokers and others as necessary within the assigned territory Develops action plans and strategies to optimize Medicare sales Partner with the Community Developer (CD) and Sales Director (SD) to identify and develop relationships with individuals and organizations that influence the buying behavior of our target consumer (e.

Sales representative for the UHC Key Accounts responsible for broker and direct sales to customers in the 100 5000 employee range. The principle focus is the sale of new fully insured and self funded business with indirect responsibility for the retention of existing accounts New Business Sales Identifies potential healthcare business customers Accountable for prospect fr