utilization management specialist

Highmark Health

<div><h2 class="jobSectionHeader">Company :
</h2>Highmark Inc.
<h2 class="jobSectionHeader">Job Description :
</h2>JOB SUMMARY
This job implements effective utilization management strategies including: review of appropriateness of health care services, application of criteria to ensure appropriate resource utilization, identification of opportunities for referral to a Health Coach/case management, and identification and resolution of quality issues. Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Responds to customer inquiries and offers interventions and/or alternatives.
ESSENTIAL RESPONSIBILITIES
<ul><li>Implement care management review processes that are consistent with established industry and corporate standards and are within the care manager&rsquo;s professional discipline.
</li><li>Function in accordance with applicable state, federal laws and regulatory compliance.
</li><li>Implement all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies.
</li><li>Promote quality and efficiency in the delivery of care management services.
</li><li>Respect the member&rsquo;s right to privacy, sharing only information relevant to the member&rsquo;s care and within the framework of applicable laws.
</li><li>Practice within the scope of ethical principles.
</li><li>Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions.
</li><li>Employ collaborative interventions which focus, facilitate, and maximize the member&rsquo;s health care outcomes. Is familiar with the various care options and provider resources available to the member.
</li><li>Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships.
</li><li>Develop and sustain positive working relationships with internal and external customers.
</li><li>Utilize outcomes data to improve ongoing care management services.
</li><li>Other duties as assigned or requested
</li></ul>EDUCATION
Required
<ul><li>None
</li></ul>Substitutions
<ul><li>None
</li></ul>Preferred
<ul><li>Bachelor&rsquo;s Degree in Nursing
</li></ul>EXPERIENCE
Required
<ul><li>3 years of related, progressive clinical experience in the area of specialization
</li><li>Experience in a clinical setting
</li></ul>Preferred
<ul><li>Experience in UM/CM/QA/Managed Care
</li></ul>LICENSES AND CERTIFICATIONS
Required
<ul><li>Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). Additional specific state licensure(s) may be required depending on where clinical care is being provided.
</li></ul>Preferred
<ul><li>Certification in utilization management or a related field
</li></ul>SKILLS
<ul><li>Working knowledge of pertinent regulatory and compliance guidelines and medical policies
</li><li>Ability to multi task and perform in a fast paced and often intense environment
</li><li>Excellent written and verbal communication skills
</li><li>Ability to analyze data, measure outcomes, and develop action plans
</li><li>Be enthusiastic, innovative, and flexible
</li><li>Be a team player who possesses strong analytical and organizational skills
</li><li>Demonstrated ability to prioritize work demands and meet deadlines
</li><li>Excellent computer and software knowledge and skills
</li></ul>Languages (Other than English)
None 
 
Travel Requirement
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-Based
Teaches/trains others regularly
Occasionally
Travel regularly from the office to various work sites or from site-to-site
Does Not Apply
Works primarily out-of-the office selling products/services (sales employees)
Does Not Apply
Physical work site required
Yes
Lifting: up to 10 pounds
Constantly
Lifting: 10 to 25 pounds
Occasionally
Lifting: 25 to 50 pounds
Rarely, Occasionally
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company&rsquo;s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee&rsquo;s responsibility to comply with the company&rsquo;s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum:
$68,400.00
Pay Range Maximum:
$105,900.00
Base pay is determined by a variety of factors including a candidate&rsquo;s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.
For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org
California Consumer Privacy Act Employees, Contractors, and Applicants Notice</div>

Care Manager RN (Remote)

<div><h2 class="jobSectionHeader">Company :
</h2>Highmark Inc.
<h2 class="jobSectionHeader">Job Description :
</h2>JOB SUMMARY
This job is responsible for completing all Prior Authorization outbound call tasks and/or inbound triage case creations. In compliance with regulatory guidelines (e.g., NCQA, CMS), the incumbent informs the member and/or provider of the approval and/or denial of the requested authorization.
 
 
ESSENTIAL RESPONSIBILITIES
<ul><li>Obtain call task from Utilization Management platform, perform verbal outbound call task requirement following a detailed script and desk level procedure, and appropriately log result within the platform.
</li><li>Obtain triage task from Utilization Management platform and follow a detailed desk level procedure to enter the required fields to set up the case build (data entry) and set the urgency of the case creation for the Intake Coordinator.
</li><li>Other duties as assigned or requested.
</li></ul>EXPERIENCE 
 
Required
<ul><li>1 year of Healthcare experience
</li><li>1 year of Customer Service experience
</li></ul>Preferred
<ul><li>1 year of Call Center experience 
</li></ul> 
SKILLS
<ul><li>Possess good written and oral telephonic communication skills
</li><li>Ability to navigate through multiple systems simultaneously
</li><li>Knowledge of administrative and clerical procedures and systems such as word processing, managing files and digital fax
</li><li>Ability to interact well with peers, supervisors, and customers 
</li></ul> 
EDUCATION 
 
Required
<ul><li>High School Diploma 
</li></ul> 
Preferred
<ul><li>None 
</li></ul> 
LICENSES or CERTIFICATIONS 
 
Required
<ul><li>None 
</li></ul> 
Preferred
<ul><li>None 
</li></ul> 
Language (Other than English):
None
Travel Requirement:
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office- or Remote-based
Physical work site required
Constantly
Travel Required
0% - 25%
Audible Speech
Frequently
Hear
Frequently
Position self or move lower on ground, under tables/desk, etc.
Occasionally
Climb
Occasionally
Drive
Never
Reach
Occasionally
Sedentary Position
Constantly
Move
Occasionally
Repetitive Motion
Constantly
Use Hands/Fingers to Handle or Feel (beyond data entry)
Occasionally
Vision - Distinguish Color
Occasionally
Vision - Far, near, Depth Perception
Occasionally
Lifting: up to 10 pounds
Constantly
Lifting: up to 20 pounds
Occasionally
Lifting: up to 50 pounds
Never
Lifting in excess of 50 pounds
Never
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
 
 
Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
 
 
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company&rsquo;s Handbook of Privacy Policies and Practices and Information Security Policy.
 
 
Furthermore, it is every employee&rsquo;s responsibility to comply with the company&rsquo;s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum:
$19.39
Pay Range Maximum:
$24.19
Base pay is determined by a variety of factors including a candidate&rsquo;s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.
For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org
California Consumer Privacy Act Employees, Contractors, and Applicants Notice</div>

Associate Intake Coordinator

Fakeeh Care Group

<div>
 
 Description
 
 
 
 Key Responsibilities and Duties:
 
 
 <ul>
 <li>
 Ensure full adherence to the Council of Health Insurance (CHI) Preauthorization Policy, NPHIES standards, and
 
 
 </li>
 </ul>
 individual payer coverage protocols.
 
 
 <ul>
 <li>
 Prevent unauthorized, uncovered, or non-contracted services from being initiated.
 </li>
 <li>
 Support the implementation and compliance of NPHIES downtime contingency procedures.
 </li>
 <li>
 Verify the completeness of clinical documentation and utilization of the Minimum Data Set (MDS) for every
 
 
 </li>
 </ul>
 request.
 
 
 <ul>
 <li>
 Review the treating physician&rsquo;s progress notes, diagnostics, prescriptions, and clinical justifications for
 
 
 </li>
 </ul>
 accuracy and adequacy.
 
 
 <ul>
 <li>
 Validate medical necessity in alignment with evidence-based guidelines, CHI standards, and payer criteria.
 </li>
 <li>
 Ensure accurate clinical coding and scheme linkage to prevent claim denials.
 </li>
 <li>
 Escalate incomplete or inaccurate documentation for correction prior to submission.
 </li>
 <li>
 Liaise with treating physicians, nurses, and roving doctors to secure approvals and clarify case details.
 </li>
 <li>
 Communicate approvals, denials, and payer queries within CHI-mandated timelines.
 </li>
 <li>
 Respond to payer or insurer queries within 30 minutes of receipt.
 </li>
 <li>
 Escalate urgent or high-priority cases (ER, ICU, Oncology, or high-cost procedures) immediately to the
 
 
 </li>
 </ul>
 Preauthorization Manager.
 
 
 <ul>
 <li>
 Monitor HIS/NPHIES queues to follow up on pending or queried cases in real time.
 </li>
 <li>
 Maintain updated approval status in both HIS and the patient&rsquo;s record.
 </li>
 <li>
 Ensure 100% completion of approvals for all discharges within the same day.
 </li>
 <li>
 Confirm that same-day discharge and high-cost cases are fully approved prior to billing.
 </li>
 <li>
 Document all approvals, denials, and payer communications in the patient&rsquo;s medical record.
 </li>
 <li>
 Participate in the daily discharge reconciliation process and report pending approvals to the Preauthorization
 
 
 </li>
 </ul>
 Manager.
 
 
 <ul>
 <li>
 Review all preauthorization rejections received through NPHIES, payer portals, or HIS at least twice per shift.
 </li>
 <li>
 Categorize rejections based on cause (missing justification, duplication, non-covered service, exceeded limit,
 
 
 </li>
 </ul>
 coding error, or late submission).
 
 
 <ul>
 <li>
 Record all rejections in the Rejection Tracker Log with patient MRN, preauthorization number, payer,
 
 
 </li>
 </ul>
 rejection reason, and physician name.
 
 
 <ul>
 <li>
 Coordinate with the Preauthorization Supervisor to ensure each rejection is reviewed and analyzed within the
 
 
 </li>
 </ul>
 assigned TAT.
 
 
 <ul>
 <li>
 Engage directly with the treating physician for clarification or missing documentation related to rejected
 
 
 </li>
 </ul>
 cases.
 
 
 <ul>
 <li>
 Provide constructive feedback and guidance to physicians to avoid recurrence, referencing insurer
 
 
 </li>
 </ul>
 preauthorization protocols, CHI guidelines and NPHIES dataset requirements.
 
 
 <ul>
 <li>
 Conduct same-day briefings for rejections involving high-cost services.
 </li>
 <li>
 Resubmit corrected documentation within the payer&rsquo;s appeal window as per the regulations.
 </li>
 <li>
 Liaise with the insurance representative or roving doctor for urgent or high-priority resubmissions.
 </li>
 <li>
 Confirm acknowledgment of resubmitted cases in both HIS and payer portals.
 </li>
 <li>
 Identify root causes for all rejections and document corrective recommendations.
 </li>
 <li>
 Distinguish between avoidable and non-avoidable rejections during end-of-day analysis.
 </li>
 <li>
 Submit a daily rejection summary to the Preauthorization Manager, covering:
 </li>
 <li>
 Total rejections received
 </li>
 <li>
 Avoidable vs non-avoidable ratio
 </li>
 <li>
 High-value or repetitive rejection patterns
 </li>
 <li>
 Breakdown by payer, physician, and service category
 </li>
 <li>
 Recommend corrective actions such as MDS checklist updates, justification templates, or focused physician
 
 
 </li>
 </ul>
 sessions.
 
 
 <ul>
 <li>
 Collaborate with Fakeeh Tech to improve HIS alerts (e.g., auto-flagging incomplete documentation or
 
 
 </li>
 </ul>
 incorrect scheme linkage).
 
 
 <ul>
 <li>
 Participate in weekly Preauthorization Group performance meetings to present rejection trends and lessons
 
 
 </li>
 </ul>
 learned.
 
 
 <ul>
 <li>
 Ensure complete transparency of all rejection cases to the Preauthorization Manager and Group
 
 
 </li>
 </ul>
 Preauthorization leadership.
 
 
 <ul>
 <li>
 Support the preparation of a Weekly Rejection Dashboard, including:
 </li>
 <li>
 Total rejection count
 </li>
 <li>
 Avoidable vs non-avoidable percentage
 </li>
 <li>
 Average approval turnaround time
 </li>
 <li>
 Top 10 contributing services, physicians, or payers
 </li>
 <li>
 Highlight immediate corrective actions taken and propose follow-up actions for recurring issues.
 </li>
 <li>
 Uphold professional communication standards and maintain formal documentation of all internal and
 
 
 </li>
 </ul>
 external correspondences.
 
 
 <ul>
 <li>
 Ensure continuous compliance with CHI, NPHIES, and contractual payer regulations in every stage of
 
 
 </li>
 </ul>
 preauthorization and rejection management.
 
 
 <ul>
 <li>
 Report any non-compliance or process deviation to the Preauthorization Manager for immediate rectification
 
 
 </li>
 </ul>
 and inclusion in preauthorization Group review.
 
 
 <ul>
 <li>
 Other duties as assigned within the scope of responsibility and requirements of the job.
 
 
 </li>
 </ul>
 
 Requirements
 
 
 
 Experience: 3&ndash;5 years clinical practice, with at least 2 years in preauthorization/insurance or
 
 
 utilization management
 
 
 Education: Bachelor&rsquo;s degree in medicine and surgery, Pharmacy, Dental or related field.
 
 
 Language: Excellent command of oral and written English and Arabic.
 
 
 
 Licenses / Certifications
 
 
 
 Preferred license for practice as per the regional health regulatory authority e.g.
 
 
 (SCFHS / DHA).
</div>

Approval Specialist

Valley Medical Center

<div></div><div><div><div><ul><li><h6 class="jobSectionHeader">Job Title:</h6>
 Clinical Documentation Specialist
</li><li><h6 class="jobSectionHeader">Req:</h6>
 2026-0293
</li><li><h6 class="jobSectionHeader">Location:</h6>
 VMC Main Campus
</li><li><h6 class="jobSectionHeader">Department:</h6>
 Health Information Mgmt
</li><li><h6 class="jobSectionHeader">Shift:</h6>
 Days
</li><li><h6 class="jobSectionHeader">Type:</h6>
 Full Time
</li><li><h6 class="jobSectionHeader">FTE:</h6>
 1
</li><li><h6 class="jobSectionHeader">Hours:</h6>
</li><li><h6 class="jobSectionHeader">City State:</h6>
 Renton, WA
</li><li><h6 class="jobSectionHeader">Salary Range:</h6>
 Min $94,894 - Max $142,341/annual DOE</li></ul></div></div> 
 
 
 
Job Description:
VALLEY MEDICAL CENTER

JOB DESCRIPTION

The position description is a guide to the critical duties and essential functions of the job, not an all-inclusive list of responsibilities, qualifications, physical demands, and work environment conditions. Position descriptions are reviewed and revised to meet the changing needs of the organization.

TITLE: Clinical Documentation Specialist RN

JOB OVERVIEW: The Clinical Documentation Specialist position facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the documentation improvement process is a key role.

DEPARTMENT: Health Information Management

HOURS OF WORK: Days Monday - Friday.

RESPONSIBLE TO: Manager, Clinical Documentation Improvement

PREREQUISITES:
<div>
<ul><li>Current unrestricted WA State Registered Nurse license, required.
</li></ul>
<ul><li>Bachelor's degree in Nursing, preferred.
</li></ul>
<ul><li>Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review
</li></ul>
<ul><li>Pass a pre-hire Clinical Exam with a minimum score of 70%
</li></ul>
<ul><li>Effective communication with Providers
</li></ul>
</div>QUALIFICATIONS:
<div>
<ul><li>Knowledge of hospital clinical practice standards for physicians and other health care providers.
</li></ul>
<ul><li>Knowledge of ancillary service departments, quality control and safety standards.
</li></ul>
<ul><li>Critical thinking, problem solving and deductive reasoning skills.
</li></ul>
<ul><li>Familiarity with health care audit and research design.
</li></ul>
<ul><li>Knowledge of Pathophysiology and Disease process.
</li></ul>
<ul><li>Functional knowledge of DRG coding systems.
</li></ul>
<ul><li>Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.
</li></ul>
<ul><li>Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.
</li></ul>
<ul><li>Meet productivity guidelines.
</li></ul>
<ul><li>Ability to learn/develop the skills necessary to perform and meet goal standards
</li></ul>
<ul><li>Organizational, analytical, writing, and interpersonal skills
</li></ul>
<ul><li>Dependable, self-directed, and pleasant
</li></ul>
<ul><li>Critical thinking, problem solving and deductive reasoning skills
</li></ul>
<ul><li>Knowledge of Pathophysiology and Disease Process
</li></ul>
<ul><li>Basic Computer skills - familiarity with Windows based software programs
</li></ul>
<ul><li>Knowledge of regulatory environment
</li></ul>
<ul><li>Understand and support documentation strategies (upon completion of training)
</li></ul>
<ul><li>Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)
</li></ul>
</div>UNIQUE PHYSICAL/MENTAL DEMANDS, ENVIRONMENT AND WORKING CONDITIONS:

See Generic Job Description for Administrative Partner.

PERFORMANCE RESPONSIBILITIES:

A. Generic Job Functions: See Generic Job Description for Administrative Partner.

B. Essential Responsibilities and Competencies
<div>
<ul><li>Reviews EMR for completeness and accuracy for severity of illness and quality using the documentation strategies.
</li></ul>
<ul><li>Accurate and timely record review.
</li></ul>
<ul><li>Recognize opportunities for documentation improvement.
</li></ul>
<ul><li>Initiates severity worksheet for inpatients.
</li></ul>
<ul><li>Formulate clinically credible documentation clarifications.
</li></ul>
<ul><li>Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety.
</li></ul>
<ul><li>Effective and appropriate communication with physicians.
</li></ul>
<ul><li>Timely follow up on all cases and resolution of those with clinical documentation clarifications.
</li></ul>
<ul><li>Communicates with HIM staff and resolves discrepancies.
</li></ul>
<ul><li>Accurate input of data for reconciliation of case.
</li></ul>
<ul><li>Provide necessary information and education to physicians and staff to facilitate the appropriate documentation goals.
</li></ul>
<ul><li>Identify any barriers to completion of documentation goals with appropriate interventions.
</li></ul>
<ul><li>Review of regulations and coding guidelines through seminars, meetings, and materials.
</li></ul>
<ul><li>In cooperation with the director of PFS/HIM, present education sessions to physicians and other VMC providers regarding documentation regulations and chart audit findings.
</li></ul>
<ul><li>Maintains confidentiality of all accessible patient financial or medical records information.
</li></ul>
<ul><li>Demonstrates the awareness of the importance of cost containment for the department. Provide suggestions regarding process or quality improvement opportunities to department manager.
</li></ul>
<ul><li>Other duties as assigned to facilitate accurate, timely patient account management.
</li></ul>
</div>Date Created: 5/18, updated 7/22

Grade: NC11

FLSA: E

Cost Center: 8490 

Job Qualifications:
PREREQUISITES:
<div>
<ul><li>Current unrestricted WA State Registered Nurse license, required.
</li></ul>
<ul><li>Bachelor's degree in Nursing, preferred.
</li></ul>
<ul><li>Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review
</li></ul>
<ul><li>Pass a pre-hire Clinical Exam with a minimum score of 70%
</li></ul>
<ul><li>Effective communication with Providers
</li></ul>
</div>QUALIFICATIONS:
<div>
<ul><li>Knowledge of hospital clinical practice standards for physicians and other health care providers.
</li></ul>
<ul><li>Knowledge of ancillary service departments, quality control and safety standards.
</li></ul>
<ul><li>Critical thinking, problem solving and deductive reasoning skills.
</li></ul>
<ul><li>Familiarity with health care audit and research design.
</li></ul>
<ul><li>Knowledge of Pathophysiology and Disease process.
</li></ul>
<ul><li>Functional knowledge of DRG coding systems.
</li></ul>
<ul><li>Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.
</li></ul>
<ul><li>Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.
</li></ul>
<ul><li>Meet productivity guidelines.
</li></ul>
<ul><li>Ability to learn/develop the skills necessary to perform and meet goal standards
</li></ul>
<ul><li>Organizational, analytical, writing, and interpersonal skills
</li></ul>
<ul><li>Dependable, self-directed, and pleasant
</li></ul>
<ul><li>Critical thinking, problem solving and deductive reasoning skills
</li></ul>
<ul><li>Knowledge of Pathophysiology and Disease Process
</li></ul>
<ul><li>Basic Computer skills - familiarity with Windows based software programs
</li></ul>
<ul><li>Knowledge of regulatory environment
</li></ul>
<ul><li>Understand and support documentation strategies (upon completion of training)
</li></ul>
<ul><li>Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)</li></ul></div></div>

Clinical Documentation Specialist

Asante

<div><div><div>Req #: 24661 
Entity: Asante Rogue Regional Medical Center 
Location: Medford OR 
Department: Case Management 
Shift: Variable Schedule Days 
Union Position: No 
FTE: 0.000001 
Schedule: On Call 
Salary: $23.28 - $32.02 depending on qualifications</div><div><div> 
</div></div></div><div>Description
Additional Position Details: FTE: 0.000001 | On Call | Variable Schedule Days
Starting Wage: $23.28-$32.02 per hour, depending on experience
Position Summary
The Case Management Specialist functions as a member of the Case Management team. They utilize communication, organizational, and problem-solving skills to carry out the post-hospital care plans and interventions, utilization review, and denials management activities as defined by the RN Discharge Coordinator and RN Utilization Reviewer. They assume a pivotal role with the patient care team to achieve optimal clinical and resource outcomes.
Position Qualifications
Experience<ul><li>
3 years of experience in administrative functions in care coordination and/or utilization management in healthcare settings is required.</li><li>
Experience with Microsoft Word and Excel is required</li><li>
Experience with EPIC is preferred</li><li>
Current understanding of CMS regulations related to hospital discharge requirements is preferred.</li></ul>
Education<ul><li>
High School Diploma, GED, or equivalent experience demonstrating the ability to effectively communicate as required for the position is required</li><li>
An Associate's degree in business, healthcare administration, or a related field is preferred</li></ul>
Total Rewards
We offer a comprehensive Total Rewards package designed to support your well-being and professional growth, including:<ul><li>
Competitive Pay: Hourly and salaried positions earn market-based compensation.</li><li>
Health &amp; Wellness: Medical, dental, and vision coverage for part-time and above employees and their eligible dependents beginning within 30 days of hire.</li><li>
Retirement Savings: Employer-sponsored retirement plan with company contribution and match.</li><li>
Paid Time Off: Generous ETO for part-time and above employees.</li><li>
Professional Development: Continue to enhance your education through our tuition reimbursement and tuition repayment program</li><li>
Additional Benefits: Life insurance, disability coverage, and employee assistance programs.</li></ul>
At Asante, we are guided by our values:
Excellence - Respect - Honesty - Service - Teamwork
Asante is proud to be an Equal Opportunity Employer. We are committed to creating a diverse and inclusive workplace and to employing and advancing qualified individuals of all backgrounds, including women, minorities, individuals with disabilities, and protected veterans.</div></div>

Case Management Specialist

Beacon Health System

<div><div><div><div><div><div>Beacon Health System is hiring a full-time day Patient Access Insurance Specialist, in our Verification of Benefits Department at Beacon Health System in South Bend, IN. 
 
Be a Beacon. Make a Difference.
At Beacon Health System, you&rsquo;re not just part of a team, you&rsquo;re part of something bigger. Every patient interaction is a chance to lead with compassion, build trust, and create lasting impact. Here, your expertise supports healing, and your heart connects us to the communities we serve.
<ul><li>Medical, Dental, &amp; Vision Insurance through Cigna</li>
</ul><ul><li>Life Insurance</li>
</ul><ul><li>403(b) Matching Retirement Fund</li>
</ul><ul><li>Competitive Paid Time Off (PTO)</li>
</ul><ul><li>Shift Differentials</li>
</ul><ul><li>Employee Assistance Program (EAP)</li>
</ul><ul><li>Tuition and Certification Reimbursement</li>
</ul><ul><li>Clinical Ladder Program</li>
</ul><ul><li>Local and National Discounts</li>
</ul><ul><li>Beacon Academy Educational Courses</li>
</ul><ul><li>Gym Membership Discount</li>
</ul>
About Beacon Health System
Headquartered in South Bend, Indiana, as a not-for-profit, community-governed health system, Beacon Health System provides care to more than 4,000 patients each day in northern Indiana and southern Michigan.
What You&rsquo;ll Do
As a Patient Access Insurance Specialist, you will report to the Patient Access Director or the Insurance Specialist Supervisor. Follows established Beacon policies and procedures to verify insurance coverage to ensure necessary procedures and hospitalizations are covered by an individual's provider. The Insurance Verification Authorization Specialist will assure authorization is obtained for all procedures and diagnostic testing to services being rendered. The Authorization Specialist will also initiate the authorization for direct admissions, emergency admissions, and emergency procedures. They will work closely with medical staff, clinical staff, referring clinics, Beacon Outpatient Scheduling Surgery Scheduling, Social Services, and Utilization Review departments. They will be responsible for communication with insurance carriers and/or providers for purposes of obtaining approval for services requiring authorization, pre-certification, and prior approval for admissions to Beacon or Epworth Center by using web-based tools, other electronic means where possible, or by telephoning and faxing when necessary. Coordinating those visits with the correct paperwork and insurance verification, along with accurate documentation in the patient's medical record is essential. They will answer high volume of incoming phone calls as well as making high volume of outbound phone calls, with constant communication to the Utilization Review, Social Services, Beacon Outpatient Scheduling and Surgery Scheduling departments. Performs other clerical duties as necessary.
Patient Access Insurance Specialist Job Responsibilities:
<ul><li>Verify and update patient demographic and financial information to ensure accuracy in the registration system.</li>
<li>Obtain and validate insurance coverage using online eligibility systems, payer portals, and telephone verification.</li>
<li>Utilize Cerner systems and reports (e.g., PHS, SurgiNet, Medical Necessity Checker) to review scheduled patients, procedures, and medical necessity requirements.</li>
<li>Audit and complete required documentation, including MSP questionnaires and insurance verification records.</li>
<li>Coordinate verification of benefits (VOB) by confirming co-pays, deductibles, coinsurance, out-of-pocket limits, and rehabilitation benefits with insurance providers.</li>
<li>Secure and document pre-authorizations and pre-certifications for ancillary, surgical, outpatient, and inpatient procedures.</li>
<li>Collaborate with physician offices, scheduling teams, and referring facilities to ensure required authorizations are obtained and procedures are properly scheduled.</li>
<li>Validate CPT and ICD-10 codes and confirm compliance with Medicare Inpatient Only Procedure (MIPO) requirements when applicable.</li>
<li>Identify out-of-network insurance plans and follow established policies and procedures.</li>
<li>Refer patients to Financial Counselors or Eligibility Specialists when financial clearance or payment arrangements are required.</li>
<li>Maintain accurate worklists, documentation, and records to support timely claim submission and reimbursement.</li>
<li>Calculate and communicate estimated patient financial responsibility, including co-payments and coinsurance.</li>
<li>Prepare reports, patient statistics, and documentation to support departmental operations and leadership requests.</li>
<li>Provide professional customer service by answering calls, communicating with patients and internal departments, and maintaining positive patient relations.</li>
<li>Collaborate with departments such as Utilization Review, Surgery Scheduling, Social Services, and Outpatient Scheduling to ensure accurate and timely patient processing.</li>
<li>Support departmental quality goals by maintaining productivity, accuracy, and compliance with Beacon policies and procedures.</li>
<li>Maintain professionalism while representing Beacon Health System and perform other duties as assigned.</li>
</ul>
What You Bring
As a Patient Access Insurance Specialist, it requires strong office and computer skills, including keyboarding (minimum 40 wpm), data entry, and proficiency with systems such as Cerner, Pathways Healthcare Scheduling, Experian, and MCA Compliance Checker. Demonstrates knowledge of medical terminology, insurance coverage, managed care networks, ICD-10 and CPT codes, and time-of-service collections, including the ability to clearly communicate financial responsibilities to patients. You will possess strong telephone, verbal communication, and listening skills to effectively interact with patients, insurance companies, physicians, and internal departments. You will maintains professionalism and sensitivity when working with diverse populations, follows strict confidentiality policies, exercises sound judgment in stressful situations, and applies basic math skills to calculate patient financial responsibilities such as deductibles, coinsurance, and out-of-pocket costs.
Required Qualifications
<ul><li>The knowledge, skills and abilities as indicated below are normally acquired through the successful completion of a high school diploma (or equivalent).
</li><li>A minimum of two years of experience in a hospital or physician practice business office is required.
</li><li>Excellent time management, organizational skills, research/analytical skills, negotiation, communication (written and verbal), and interpersonal skills required.</li>
<li>A medical terminology course must be successfully completed prior to employment.
</li><li>Associate's degree preferred.
</li><li>Medical prior authorizations or claims experience in a managed care setting and CHAA certification are highly preferred.</li>
</ul>
The Beacon Way
At Beacon Health System, our approach to care goes beyond clinical excellence because it&rsquo;s built on meaningful connections. Guided by our core values of Trust, Respect, Integrity, and Compassion, we strive to create an environment where patients feel heard, employees feel valued, and innovation thrives.
We call this commitment The Beacon Way&mdash;a six-point operating system that empowers every team member to lead with purpose, communicate clearly, cultivate talent, embrace performance improvement, leverage innovation, and build greatness through accountability. Whether at the bedside or behind the scenes, everyone at Beacon plays a role in moving health forward.</div> 
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Location: Beacon Health System &middot; Verification of Benefits 
Schedule: Full-time, Day, 0830-5pm M-F</div>

Patient Access Insurance Specialist, Verification of Benefits Department, Full-Time Days

Amazon

<div>
 
 Description
 
 
 
 We are looking for a continuous improvement junior specialist which is a role referred to internally as ACES Specialist, to drive cost and efficiency charter within Amazon logistics and transportation services.
 
 
 As an ACES (Amazon Customer Excellence Systems) Specialist, you will drive process standardization in Egypt last mile logistics operations. As a member of the ACES team itself, you will contribute to the optimization of the delivery stations, first mile stations, line haul operations while providing operations team with sufficient knowledge and appropriate tools to improve performance.
 
 
 Key job responsibilities
 
 
 As a primary contact for delivery station management regarding process improvements and efficiency programs, you will support monitoring the logistics and delivery success through in-station and on-road performance indicators. You will set up actions plans and execute them to drive current performance to benchmark results.
 
 
 You will work towards improving OTR (on the road), UTR (under the roof), Linehaul performance, mainly productivity metrics like shipments per route, truck utilization, throughput per hour, process path rates, deliveries per paid hour etc.
 
 
 Additionally, you will be contributing to deployment of process standards and upgrades within the delivery station partnering with station management and several stakeholders.
 
 
 This role will be based in the delivery stations. You will be required to work in non-traditional shift patterns which include night.
 
 
 
 About The Team
 
 
 
 You will be joining ACES EG cost and productivity team, focusing on EG productivity improvement agenda.
 
 
 
 Basic Qualifications
 
 
 
 <ul>
 <li>
 Experience in logistics
 </li>
 <li>
 Knowledge of city topography and road network
 </li>
 <li>
 Speak, write, and read fluently in English
 
 
 </li>
 </ul>
 
 Preferred Qualifications
 
 
 
 <ul>
 <li>
 1+ years of manufacturing or customer-facing environment experience
 </li>
 <li>
 Bachelor's degree
 
 
 </li>
 </ul>
 Our inclusive culture empowers Amazonians to deliver the best results for our customers. If you have a disability and need a workplace accommodation or adjustment during the application and hiring process, including support for the interview or onboarding process, please visit https://amazon.jobs/content/en/how-we-hire/accommodations for more information. If the country/region you&rsquo;re applying in isn&rsquo;t listed, please contact your Recruiting Partner.
 
 
 
 
 Company
 
 - Souq.com for E-Commerce LLC
 
 
 Job ID: A3184795
</div>

ACES Specialist, AMZL Trans

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