utilization manager

WellSpan Health

<div>Full time

Monday-Friday 0800-1630

No Holidays and Occasional weekend

General Summary

Performs a variety of duties and applies utilization and case management techniques to determine the most efficient use of resources to facilitate a patient's progression of care and the provision of appropriate, cost effective and quality health care. Works in a team model with social work in assigned patient care areas to address patient discharge needs. Provides leadership in the integration of utilization and case management principles.
Duties and Responsibilities 
 
Essential Functions:
<ul>
<li>Reviews assigned patients for medical necessity, utilization management, and appropriateness of setting for continued hospitalization.</li>
<li>Initiates problem-solving techniques to prevent over and/or under utilization.</li>
<li>Facilitates and coordinates the progression of patient care to optimize throughput and the utilization of resources to support continuous quality and cost of care efforts.</li>
<li>Liaisons between utilization management team, third party payers, and the treatment team regarding the identified treatment plan in accordance with contractual guidelines and System policy.</li>
<li>Assists the patient care team with the identification and coordination of alternative treatment settings to provide appropriate care, maintain quality of care, and reduce cost.</li>
<li>Identifies conditions which require case management across the care continuum. Collaborates with members of the patient care team to identify interdisciplinary needs</li>
<li>Collaborates with care management across the system to effectively transition patient care and support value-based care initiatives.</li>
<li>Completes case management patient assessment, identifies needs, develops a discharge plan, and coordinates discharge needs (DME, Home Health, IV antibiotics, etc.) in collaboration with patients, families, and care team.</li>
<li>Assists with the collection and analysis of utilization patterns, length of stay, readmissions, avoidable days, and denied cases.</li>
<li>Brings known or suspected problems of under-, over-, or inappropriate utilization of resources to the attention of the appropriate manager(s).</li>
</ul>
Common Expectations:
<ul>
<li>Demonstrates a commitment to patient, visitor, and staff by complying with all applicable safety regulations, learning the impact of medical errors and methodology that will lead to reduction of errors; reporting actual and potential errors, as well as hazardous conditions; identifying opportunities to standardize processes and &ldquo;error proof&rdquo; systems that will lead to increased safety; and participating in safety education programs and root cause analyses as required.</li>
<li>Prepares and maintains appropriate documentation as required.</li>
<li>Maintains established policies and procedures, objectives, quality assessment and safety standards.</li>
<li>Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.</li>
<li>Prepares and presents utilization data analysis as required.</li>
<li>Participates in the development and delivery of educational information and process improvements related to job accountabilities and case management principles.</li>
<li>Attends meetings as required.</li>
</ul>
Benefits Offered:
<ul>
<li>Comprehensive health benefits</li>
<li>Flexible spending and health savings accounts</li>
<li>Retirement savings plan</li>
<li>Paid time off (PTO)</li>
<li>Short-term disability</li>
<li>Education assistance</li>
<li>Financial education and support, including DailyPay</li>
<li>Wellness and Wellbeing programs</li>
<li>Caregiver support via Wellthy</li>
<li>Childcare referral service via Wellthy</li>
</ul>
Qualifications 
 
Minimum Education:
<ul>
<li>Associates Degree Required</li>
<li>Bachelors Degree Preferred</li>
</ul>
Work Experience:
<ul>
<li>2 years Recent acute care experience Required</li>
<li>Field of Experience in Utilization Management, Case Management, or Clinical Nursing Specialty. Preferred</li>
</ul>
Licenses:
<ul>
<li>Licensed Registered Nurse Upon Hire Required or</li>
<li>Registered Nurse Multi State License Upon Hire Required and</li>
<li>Basic Life Support Upon Hire Required</li>
<li>Certified in Case Management Preferred</li>
</ul>
Knowledge, Skills, and Abilities:
<ul>
<li>Excellent interpersonal and communication skills.</li>
<li>Basic computer skills.</li>
<li>Desire and ability to work in a supportive and collaborative team environment.</li></ul></div>

Case Manager - Full time

Tri-City Medical Center

<div>Job Locations: US-CA Overview:

Tri-City Medical Center has served San Diego County&rsquo;s coastal communities of Carlsbad, Oceanside and Vista, as well as the surrounding region for more than 60 years and is one of the largest employers in North San Diego County. Tri-City is administered by the Tri-City Healthcare District, a California Hospital District. As a full-service acute care public hospital with over 500 physicians practicing in over 60 specialties, Tri-City is vital to the well-being of our community and serves as a healthcare safety net for many of our citizens. The hospital has received a Gold Seal of Approval&reg; from the Joint Commission showcasing a commitment to safe and effective patient care for the residents of the community.
Tri-City Medical Center prides itself on being the home to leading orthopedic, spine and cardiovascular health services while also specializing in world-class robotic surgery, cancer and emergency care. Tri-City&rsquo;s Emergency Department is there for your loved ones in their time of need and is highly regarded for our heart attack and stroke treatment programs. When minutes matter Tri-City is your source for quality compassionate care close to home. Tri-City partners with over 90 local non-profit and community organizations as part of our COASTAL Commitment initiative. Together we are helping tackle some of our communities&rsquo; pressing health and social needs. 
Position Summary:<div>
The Case Manager II assumes responsibility for the coordination of services in order to maximize patient outcomes. Inherent in the position is assessment, evaluation, collaboration and coordination of patient care delivery systems and participation in appointed service line activities. Emphasis is on cost-effective and cost-efficient strategies which maximize quality care within the current health care environment for the identified patient population. The Case Manager II is responsible for the coordination of utilization management, discharge planning and other health care services/systems. The Case Manager II functions as a contact person, coordinator and facilitator for the patient, family, health care team members and claims/insurance personnel as necessary.</div> 
Major Position Responsibilities:
The position characteristics reflect the most important duties, responsibilities and competencies considered necessary to perform the essential functions of the job in a fully competent manner. They should not be considered as a detailed description of all the work requirements of the position. The characteristics of the position and standards of performance may be changed by TCMC with or without prior notice based on the needs of the organization.<ul><li>
Patient Care:<ul><li>
Conduct comprehensive assessments to identify patient needs and develop individualized discharge care plans.</li><li>
Responsible for the coordination of services in order to maximize patient outcomes.</li><li>
Assess, evaluate, collaborate and coordinate patient care delivery systems and participation in appointed service line activities.</li><li>
Responsible for the coordination of utilization management, discharge planning and other health care services/systems.</li><li>
Functions as a contact person and facilitator for the patient, family, health care team members and claims/insurance personnel as necessary.</li><li>
Act as a patient advocate, ensuring dignity and confidentiality.</li><li>
Demonstrate empathy and compassion for patient experience.</li><li>
Advocate for evidence-based practices in case management and utilization review.</li></ul></li><li>
Safety and Compliance:<ul><li>
Maintain a safe, clean working environment, adhering to infection control and hospital policies.</li><li>
Comply with regulatory standards (e.g., The Joint Commission, OSHA).</li><li>
Identify and report safety concerns proactively.</li><li>
Ensures cost-effective and cost-efficient strategies which maximize quality care within the current health care environment for the identified patient populations.</li></ul></li><li>
Documentation:<ul><li>
Accurately document assessments and patient interactions in the Electronic Health Record (EHR) according to Department Standards</li></ul></li><li>
Professional Development and Leadership:<ul><li>
Provide preceptorship and mentorship to New Graduate Nurses, New Hires, and students, supporting their professional development.</li><li>
Participate in continuing education and quality improvement initiatives.</li><li>
Serve as a resource for best practices within Case Management.</li></ul></li><li>
Emergency Preparedness:<ul><li>
Activate emergency response system during patient emergencies (e.g., Rapid Response Team (RRT) situations).</li></ul></li></ul><div></div> 
Qualifications:
<ul><li>Two (2) years of experience as a Registered Nurse in case management or utilization management, required</li><li>
Knowledge of Prospective Payment System and The Joint Commission standards and regulatory requirements pertaining to Utilization Management and Discharge Planning required.</li></ul><div>
Competencies:</div><ul><li>
Technical Skills:<ul><li>
Proficient computer skills, including Word.
</li><li>Knowledge and understanding of various payer types
</li><li>Experience with referral management system, preferred</li></ul></li><li>
Critical Thinking:<ul><li>
Rapid decision-making skills and ability to pivot plans on short notice</li><li>
Ability to prioritize tasks</li></ul></li><li>
Communication:<ul><li>
Effective verbal and written communication with the patients, families, and the multidisciplinary team.
</li><li>Strong interpersonal skills to support a collaborative team environment.</li></ul></li></ul>
Education:<ul><li>
Bachelor of Science in Nursing (BSN) or may consider Associate Degree, Nursing (ADN) with 5 years&rsquo; experience as a Registered Nurse in case management in lieu of BSN, required.</li></ul><div>
 Licenses:</div><ul><li>
Current California Registered Nurse, required.
</li></ul>Certification:<ul><li>
Accredited Case Manager (ACM) or Certified Case Manager (CCM), or equivalent certification, preferred.</li></ul> 
Each new hire candidate who is offered employment must pass a physical evaluation, urine drug screen and pre-employment background checks before starting work.<ul><li> 
Salary/Hourly Wage range based on experience.
</li></ul>TCHD is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex (including pregnancy, sexual orientation, or gender identity/expression), age, marital status, status as a protected veteran, among other things, or status as a qualified individual with a disability.</div>

CASE MANAGER II

Yale New Haven Health

<div>Overview: To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day. 
 
The Case Manager is responsible and accountable for ensuring high-value patient care that is coordinated, efficient, and aligned with institutional clinical and financial objectives. In collaboration with the healthcare team, the Case Manager utilizes evidence-based practice to ensure that specific patient outcomes are reliably achieved and that resources are appropriately used within designated fiscal time frames. With our members of the health care team, the Case Manager participates in the ongoing evaluation of practice patterns and supports efforts to improve patient care and enhance the efficiency of operations. The Case Manager interacts with others in the identification of trends and barriers to all aspects of care. Through this interaction, the Case Manager identifies and works toward a resolution as a part of the multidisciplinary team. 
 
EEO/AA/Disability/Veteran Responsibilities:
<ul><li><div>1. As part of the interdisciplinary health care team, coordinates and ensures the implementation of the plan of care, utilizing the principles of case management.</div></li><li><ul><li><div>
1.1 Establishes a system for coordinating the care of a patient throughout the continuum of care, linking the inpatient care with outpatient care, services, and case management.</div></li></ul></li><li><div>
2. Optimizes the efficiency of hospital systems which impact quality and/or length of stay</div></li><li><ul><li><div>
2.1 Identifies and monitors compliance with documenting variances from established parameters in the clinical pathway or treatment plan.</div></li></ul></li><li><div>
3. Utilizes information obtained from various resources available to:</div></li><li><ul><li><div>
3.1 Ensure that each patient meets the clinical needs for admission, treatment, and discharge and initiates appropriate follow through with the health care team.</div></li></ul></li><li><div>
4. Assist clinicians in documenting the appropriateness of admissions and continued stays</div></li><li><ul><li><div>
4.1 Responsible for Medicare notices of non-coverage and help provide appropriate documentation to appeal inappropriate denials.</div></li></ul></li><li><div>
5. Ensures that an appropriate discharge plan is developed and implemented with the health care teams members to include:</div></li><li><ul><li><div>
5.1 Identifying service, treatment, and funding options;</div></li></ul></li><li><div>
6. Ensures that the discharge plan provides a continuum of care with the appropriate outpatient physician and needed services.</div></li><li><div>
7. Ensure that the appropriate outside agencies are contacted and necessary referrals are initiated and followed through.</div></li><li><ul><li><div>
7.1 Links patient and family with the appropriate institutional or community resources, advocating on their behalf for scarce resources, and developing new resources where gaps exist in the service continuum.</div></li></ul></li><li><div>
8. Works collaboratively with PSM and unit leadership team to actively involve clinical nurses in the assessment and planning for patient's discharge to facility.</div></li><li><div>
9. Along with other members of the health care team, acts as a patient advocate.</div></li><li><ul><li><div>
9.1 Exhibits awareness of ethical/legal issues concerning patient care and strives to manage situations to reduce risk.</div></li></ul></li></ul>
Qualifications:

EDUCATION 
Minimum of a Baccalaureate degree in clinically related field. R.N. required 
EXPERIENCE 
Minimum of three (3) years of relevant clinical experience 
LICENSURE 
Active RN Licensure in Connecticut 
SPECIAL SKILLS 
Recent appropriate nursing experience, theoretical knowledge of the nursing process, case management and continuity of care. Advanced communication and interpersonal skills with all levels of internal and external customers. Ability to obtain and interpret information appropriate to patient needs and age. Advanced assessment and teaching skills. Leadership skills in planning and managing patient care as acquired through greater than 3 years of clinical nursing experience in an acute care hospital. Utilization management and case management experience preferred. Knowledge of computer software and hardware applications and a basic knowledge of statistics. 
PHYSICAL DEMAND 
50% sedentary; sitting, standing, walking from unit to unit, carrying records, speaking before groups. Must be able to speak and hear in a manner understood by most people. Must be able to communicate effectively by telephone.</div>

Case Manager

Williamson Health

<div>ABOUT WILLIAMSON HEALTH | Williamson Health is a regional healthcare system based in Williamson County, Tennessee, with more than 2,300 employees across more than 30 locations and more than 860 physicians and advanced care practitioners offering exceptional healthcare across 60-plus specialties and subspecialties close to home. The flagship facility, Williamson Medical Center, which recently opened its new Boyer-Bryan West Tower, offers extensive women&rsquo;s services, state-of-the-art cardiology services, advanced surgical technologies, an award-winning obstetrics and NICU, leading-edge orthopaedics, outpatient imaging services, and distinct comprehensive emergency and inpatient services for both adult and pediatric patients. Other Williamson Health service providers include the Bone and Joint Institute of Tennessee, The Turner-Dugas Breast Health Center, Monroe Carell Jr. Children&rsquo;s Hospital Vanderbilt at Williamson Medical Center, Williamson Health physician practices that are strategically located throughout the community, countywide Emergency Medical Services that include 18 rapid response units, Williamson Health Foundation, and multiple joint venture Vanderbilt Health and Williamson Medical Center Walk-In Clinics in Williamson County. Learn more about our many specialized services at WilliamsonHealth.org.
Williamson Health is a system where your talents will be valued and your skillset expanded. We are rooted in our promise to world-class, compassionate care for the residents of Williamson County and surrounding communities, taking exceptional pride in serving our community. We&rsquo;re committed to empowering our employees to work in innovative ways and reserve time and space for curiosity, laughter and creativity. We value and support the diversity and cultural differences among one another and are committed to upholding an inclusive environment that appreciates the uniqueness of all individuals. Our values are at the heart of everything we do: respect for every individual, the health and total well-being of all people, human compassion and integrity. These shape who we are as an organization and are essential for delivering the highest level of culturally competent care and treatment of every patient, family member, visitor, physician and employee.
Williamson Health is pleased to offer a comprehensive benefits program, that offers you choice and flexibility, so you can take charge of your physical, financial, and emotional well-being. 
o Medical, Dental, Vision 
o PTO 
o Retirement Matching 
o Tuition reimbursement 
o Discount programs 
o FSA (Flexible Spending Accounts) 
o Identity Theft Protection 
o Legal Aid
Williamson Health is an equal-opportunity employer and a drug-free workplace. 

POSITION SUMMARY
To perform the activities of Case Management and Utilization Management to facilitate the collaborative management for an entire episode of care for all patients with the multidisciplinary health care team, focusing on resource management and discharge planning. Performs timely review and delivery of necessary clinical information according to governmental regulations and insurance guidelines for approval of hospital care and correct admission status optimizing appropriate reimbursement for services, while supporting the mission of Williamson Health.
POSITION REQUIREMENTS
Formal Education / Training:
<div><ul><li>Must be currently licensed by the State of Tennessee as a Registered Nurse.</li></ul>
<ul><li>Emergency Room and or Critical Care preferred</li></ul>
<ul><li>Case Management Certification preferred/required within 3 years of employment</li></ul>
<ul><li>Earned a nursing diploma or degree from a college or university</li></ul>
</div>
Workplace Experience: 
Recent minimum 5 years related experience in hospital or managed care setting. 
Prior utilization/case management experience is preferred.
Equipment and Skills Training: 
Demonstrated clinical knowledge base in medical/surgical nursing and or critical care. 
Demonstrated organization, time management, problem-solving and critical thinking skills. 
Able to perform independently and in team situations under the supervision of a Director/Manager. 
Demonstrated effective verbal and written communication skills. 
Efficient review and interpretation of the medical record. 
Familiar with Meditech, Allscripts Care Management, Fax, Copier, basic computer skills preferred. 
General knowledge of Governmental and Insurance guidelines related to case management compliance, reimbursement, DRG system and Interqual Criteria preferred. 
Positive attitude with a willingness to learn new processes and adjusts well to change. 
Required Weekend Rotation
Physical Environment: 
Office and Clinical environment. 
Possible exposure to airborne pathogens.
Physical Effort: 
Telephone and computer use for extended periods of time. 
Able to walk/stand, up to 2 hours/day. 
Clear legible handwriting 
Clear understandable voice. 
 
PERFORMANCE STANDARDS 

<div><ul><li>Consistently sets priorities and exhibits efficient time management skills with assigned workload within the confinements of scheduled shift.</li></ul>
<ul><li>Timely reviews patients within 24 hours or next business day after admission and at a minimum of every 2 days thereafter for continued stay, applying appropriate criteria (Interqual&reg;) and facilitating reimbursement for services with third payer parties, obtaining and entering authorization number/approval status and notes in Meditech.</li></ul>
<ul><li>Completes assessments and initial status revision within 24 hours or next business day, documenting in Meditech/Allscripts.</li></ul>
<ul><li>Maintains precise, timely, and appropriate documentation in Allscripts and Meditech. Maintains legible, pertinent documentation on the patient&rsquo;s hard copy face sheet</li></ul>
<ul><li>Maintains knowledge of assigned patient&rsquo;s clinical condition, plan of care, discharge plan and payer source information as demonstrated in group and individual discussions</li></ul>
<ul><li>Timely delivery of the Initial and Follow-up Important Message Notification according to departmental policy for 75% of assigned and appropriate patients.</li></ul>
<ul><li>Assists in patient conversations and delivery of information related to discharge choices/discharge appeals and actively facilitates in the Discharge Appeals process.</li></ul>
<ul><li>Initiates peer to peer and initial appeal process as shown by consistent, clear communication to the physician and denials/appeals coordinator within 24 hours or next business day of notification of denial and documentation in Meditech/Allscripts &amp;/or BAR.
</li></ul><ul><li>Accurate and timely completion of all steps of the code 44 process after referral to E HR for those patients not meeting admission criteria. Complete documentation which includes hard copy forms, ensuring the status order is entered and correct in the Medical Record followed by documentation in Meditech, BAR and condition code is entered.
</li></ul><ul><li>Timely notification to Physician, social worker, and patient of NOTA status with delivery of ABN, HINN-1 or HINN-10 when appropriate</li></ul>
<ul><li>Collects and enters avoidable days, saved days and denied days in Allscripts, reporting trends to Director/Manager
</li></ul></div> 
Location: Williamson Medical Center &middot; WMC CASE MANAGEMENT 
Schedule: Full Time, Days, 8-4:30</div>

Registered Nurse - Case Manager Full Time Days

UF Health Shands Hospital

<div>Overview:

Facilitates the transition of a patient and family from one environment to another by providing them with a comprehensive continuous plan of care; e.g., arranging transportation, preparing information to facilitate patient's movement to the most appropriate level of care.
Qualifications:

Minimum Education and Experience Requirements: BSW, Bachelor's degree, or LPN required. 
<ul><li>
Screening and assessment skills and expertise in care coordination and/or utilization management in a health care setting required.</li></ul> 
<ul><li>
Five or more years of related experience may be substituted for the credentials.</li></ul> 
<ul><li>
Motor Vehicle Operator Designation: Employees in this position: Will not operate vehicles for an assigned business purpose NOTE: A frequent driver is defined as one who uses his/her personal or Shands automobile a) at least once daily, b) at least five individual trips per week or c) drives, on average, over 150 miles per week in the performance of his/her job.</li></ul> 
<ul><li>
Licensure/Certification/Registration: Active and current appropriate licensure through the Department of Professional Regulation, State of Florida as indicated</li></ul></div>

Discharge Facilitator | Case Management | Day Shift | Full Time

Moda Health

<div>Let&rsquo;s do great things, together!
About Moda 
Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we&rsquo;re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let&rsquo;s be better together. 
Position Summary 
This limited-duration, grant-funded position supports the EOCCO Health Related Social Needs (HRSN) Operations team by coordinating housing-related benefits and providing direct navigation services to Medicaid members. Primary responsibilities include authorizing housing, utility, and tenancy support benefits, and guiding members through post-service navigation. Additional duties may include support for climate benefit, home modification, and home remediation authorizations. 
 
This position fulfills contractual obligations with the Oregon Health Authority (OHA) ensuring collaboration between health plans and community partners in overseeing the utilization of services by all members, particularly those that make up the prioritized populations identified in various Oregon Administrative Rulings.
 
This is a temporary, limited duration position that is expected to conclude on September 30, 2027. This role is a hybrid based in Portland, Oregon. 
 
Pay Range<div>
$53,591.76 - $62,000 annually (depending on experience) 
<ul><li>This role may be classified as hourly (non-exempt) depending on the applicant's location. Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.</li></ul></div> 
Please fill out an application on our company page, linked below, to be considered for this position.
https://j.brt.mv/jb.do?reqGK=27773668&amp;refresh=true 
Benefits:<ul><li>
Medical, Dental, Vision &amp; Pharmacy</li><li>
PTO and Company Paid Holidays</li><li>
401k - Matching</li></ul> 
Required Skills, Experience &amp; Education:<ul><li>
2+ years of experience in healthcare, public health, member navigation, or community-based organizations, with rural or underserved communities.</li><li>
Traditional Health Worker (THW) certification preferred, or willing to obtain within 6 months of hire.</li><li>
Strong understanding of HRSN and Medicaid complexities.</li><li>
Familiarity with Oregon&rsquo;s housing landscape including HUD, Section 8, and other housing resources.</li><li>
Experience in a medical office, social work, case management, or utilization management preferred.</li><li>
Proficiency in Microsoft Office (Word, Excel, Outlook, PowerPoint).</li><li>
Ability to type at least 60 wpm net.</li><li>
Excellent oral, written, and interpersonal communication skills.</li><li>
Experience communicating with members and providers via phone, email, and written correspondence.</li><li>
Ability to advocate for member needs and contribute to process improvements.</li><li>
Strong analytical, organizational, and problem-solving skills.</li><li>
High attention to detail and ability to meet deadlines.</li><li>
Ability to work under pressure in a complex and rapidly changing environment.</li><li>
Ability to maintain confidentiality and the organization professionally in the community.</li></ul> 
Primary Functions:<ul><li>
Conduct eligibility screenings for HRSN benefit requests, including outreach to members, providers, and other entities.</li><li>
Provide outreach and engagement to members presumed eligible for the HRSN housing benefit.</li><li>
Deliver housing navigation services throughout the duration of member&rsquo;s benefit authorization.</li><li>
Offer additional outreach to members as needed to provide support services or connect them to other resources.</li><li>
Educate members and providers on HRSN services, including eligibility criteria, coverage, and available resources.</li><li>
Partner with landlords, property managers, and utility companies to facilitate benefit delivery and provide education.</li><li>
Collaborate with the HRSN Manager or RN on complex cases.</li><li>
Coordinate benefit ordering and track items approved through HRSN benefits.</li><li>
Initiate and manage payments for approved services (rent, utilities) via check request or online payment.</li><li>
Prepare and send required correspondence to members, providers, and internal departments to identify support persons and notify EOCCO-designated care coordination staff.</li><li>
Complete documentation to support compliance deliverables and reporting throughout the year.</li><li>
Maintain accurate documentation of all member and provider interactions in core systems.</li><li>
Provide data entry and tracking for HRSN program metrics and reporting.</li><li>
Utilize internal systems (CCA, Facets, benefit tracker) for eligibility and benefit verification.</li><li>
Ensure adherence to HIPPA and other regulatory guidelines, including privacy and security.</li><li>
Maintain a 98% quality audit score for care planning documentation.</li><li>
Identify and troubleshoot issues related to benefit delivery or member support.</li><li>
Collaborate with internal teams to ensure coordinated care to meet member needs.</li><li>
Remain current on all Oregon Health Authority guidance regarding HRSN benefits.</li><li>
Perform other duties as assigned.</li></ul> 
Working Conditions &amp; Contact with Others:<ul><li>
Office environment with extensive close PC and keyboard use, constant sitting, and frequent phone communication. Must be able to navigate multiple computer screens. A reliable, high-speed, hard-wired internet connection required to support remote or hybrid work. Must be comfortable being on camera for virtual training and meetings. Work in excess of standard workweek, including evenings and occasional weekends, to meet business need.</li><li>
Internally with Healthcare Services, Case Management, Claims and other various departments. Externally with members, HRSN service providers, property managers, utilities companies, community-based organizations, and other health systems across service area.</li></ul> 
Together, we can be more. We can be better.
 
Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training. 
 
For more information regarding accommodations please direct your questions to Kristy Nehler and Danielle Baker via our humanresources@modahealth.com email.</div>

Social Health Housing Benefit Coordinator -Temporary

Physicians Data Trust

<div><ul><li>Primary Purpose</li></ul>
To provide high-level customer service to PDTs&rsquo; clients with accuracy.<ul><li>
Principal Duties and Responsibilities - *Goals on Performance Review</li></ul><ul><li>
Answer calls from members, providers, and health plans regarding specific claim issues. Route and redirect calls as necessary.</li><li><ul><li>Return calls from the UM voicemail box within 24 hours</li><li>Perform timely follow-up on calls requiring research and call back within 24 hours.</li></ul></li><li>
Accurately interpret DOFRs &ndash; Division of Financial Responsibility documents to determine where specific health care services are rendered.</li><li>
Verify eligibility &amp; benefits for each submitted physician referral by contacting health plans for pertinent information.</li><li>
Work with contracting personnel to ensure the utilization of appropriate providers.</li><li><ul><li>Provide requested referral and network information to providers/staff promptly within 24 hours.</li></ul></li><li>
Use MedMC to log incoming calls and their resolution.</li><li>
Complete other projects as assigned by the supervisor</li><li>
Job Specifications (KSAs):<ul><li>
Requires the ability to speak, read, write, and understand English and other general educational skills, as is generally obtained by completing high school or a GED.</li><li>
Knowledge of the health or managed care industry is generally obtained through 1-2 years of work experience.</li><li>
Excellent communication skills with a focus on superior telephone etiquette.</li><li>
1-2 years of customer service experience required.</li></ul></li></ul>
 IV Position Performance Criteria<ul><li>
Ability to organize and maintain multiple sets of information and data.</li><li>
Consistently produces accurate and timely work as it relates to departmental goals.</li><li>
Demonstrates high reliability through consistent punctuality and attendance.</li><li>
Competently performs position requirements with minimal supervision and direction, including taking initiative and assuming responsibility for follow-through.</li><li>
Uses sound judgment regarding time management and prioritization of work to balance multiple tasks and meet required timeframes for all administrative activities as required.</li><li>
Demonstrates excellent interpersonal skills as discerned through observation and team project successes.</li><li>
Accurately interprets and applies departmental policies and procedures using sound judgment.</li><li>
Communicates professionally and respectfully with peers, superiors, subordinates, and clients.</li><li>
Provides constructive feedback on assigned work projects.</li><li>
Demonstrates overall professionalism in attitude, demeanor, and personal appearance.</li></ul></div>

Utilization Management Customer Service

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