utilization review specialist

TEEMA

<div>Job Summary
Prior Authorization
TeemaGroup
Full-time
In-Office | White Plains, NY, United States 
Overview: 
The Prior Authorization &amp; Billing Specialist plays a critical role in ensuring timely access to mental health services by managing insurance authorizations, billing processes, and reimbursement workflows. This position serves as a key liaison between clinical teams, insurance payers, and patients, ensuring services are authorized, accurately billed, and compliant with regulatory and payer requirements. This role is ideal for a detail-oriented professional passionate about supporting behavioral health access through strong administrative and revenue cycle expertise. 
 
What you will be doing: 
Prior Authorization &amp; Utilization Management<ul><li>
Obtain and manage prior authorizations for outpatient and inpatient mental health services, including therapy, psychiatry, psychological testing, and intensive programs.</li><li>
Review clinical documentation to ensure medical necessity and payer compliance.</li><li>
Submit authorization requests to insurance companies via portals, phone, or electronic systems.</li><li>
Track authorization approvals, denials, expirations, and extensions; proactively follow up to prevent treatment delays.</li><li>
Communicate authorization status clearly with clinicians, scheduling staff, and leadership.</li><li>
Assist with peer-to-peer reviews and appeals when authorization is denied or partially approved.</li></ul>
Billing &amp; Revenue Cycle Support<ul><li>
Submit accurate and timely claims for mental health services to commercial, Medicaid, and Medicare payers.</li><li>
Verify insurance eligibility, benefits, and coverage limitations prior to services.</li><li>
Review Explanation of Benefits (EOBs) and remittance advice for accuracy.</li><li>
Identify, research, and resolve claim denials, underpayments, and rejections.</li><li>
Post payments and adjustments accurately when applicable.</li><li>
Maintain compliance with CPT, ICD-10, and modifier guidelines specific to behavioral health billing.</li></ul>
Administrative &amp; Compliance Responsibilities<ul><li>
Maintain accurate patient authorization and billing records within electronic health record (EHR) and billing systems.</li><li>
Ensure compliance with HIPAA, payer contracts, and internal policies.</li><li>
Collaborate with clinical, administrative, and finance teams to optimize workflows and reduce revenue leakage.</li><li>
Monitor payer requirements, policy changes, and authorization rules related to mental health services.</li><li>
Prepare reports related to authorization turnaround times, denial trends, and billing performance.</li><li>
Perform other related duties as assigned.</li></ul> 
What you must have: 
Education and Experience<ul><li>
High school diploma or equivalent required; associate or bachelor&rsquo;s degree in healthcare administration or related field preferred.</li><li>
Minimum of 2 years of experience in prior authorization, utilization review, medical billing, or revenue cycle operations.</li><li>
Experience in mental health or behavioral health services strongly preferred.</li></ul>
Knowledge, Skills, and Abilities<ul><li>
Strong understanding of prior authorization processes and insurance requirements.</li><li>
Knowledge of behavioral health billing practices, CPT and ICD-10 coding, and payer guidelines.</li><li>
Excellent attention to detail and organizational skills.</li><li>
Ability to manage multiple priorities in a fast-paced environment.</li><li>
Strong written and verbal communication skills, including professional interaction with payers and clinical staff.</li><li>
Ability to work independently while collaborating effectively with a team.</li><li>
Proficiency with EHR systems, billing software, and Microsoft Office applications.</li></ul> 

#Workwolf</div>

Billing Specialist

SANCTUARY

Overview We are seeking a dedicated and compassionate Case Manager to join our dynamic healthcare team. In this vital role, you will coordinate patient care plans, facilitate communication among multidisciplinary teams, and ensure seamless discharge planning and utilization management. Your expertise will help optimize patient outcomes, improve hospital efficiency, and support patients through complex medical journeys. This position offers an exciting opportunity to make a meaningful impact in a fast-paced, patient-centered environment.Responsibilities<ul><li>Assess patient needs through comprehensive intake and evaluation processes, including medical terminology review and social work considerations. </li><li>Develop personalized care plans that incorporate critical care experience, hospital experience, and behavioral health insights. </li><li>Coordinate with healthcare providers across specialties such as ICU, emergency medicine, pediatrics, and trauma centers to facilitate appropriate care delivery. </li><li>Manage discharge planning by collaborating with patients, families, and interdisciplinary teams to ensure smooth transitions from hospital to home or other care settings. </li><li>Conduct utilization review and utilization management activities to ensure compliance with healthcare policies like HIPAA and managed care standards. </li><li>Document all case management activities accurately within EMR (Electronic Medical Records) and EHR (Electronic Health Records) systems while maintaining confidentiality. </li><li>Support patients through complex medical processes such as CPT coding, ICD-9/10 coding, and medical terminology interpretation for billing and documentation purposes.</li></ul>Skills<ul><li>Proven experience in critical care, hospital medicine, or emergency medicine settings with a strong understanding of ICU, PICU, or Level I/II trauma center operations. </li><li>Expertise in discharge planning, intake procedures, utilization review, and managed care protocols. </li><li>Familiarity with EMR/EHR systems, HIPAA regulations, and medical coding including ICD-10/ICD-9/ CPT coding standards. </li><li>Knowledge of hospice care principles, behavioral health practices, and social work strategies to support diverse patient populations. </li><li>Strong communication skills to collaborate effectively with multidisciplinary teams across acute care environments. </li><li>Ability to navigate complex medical terminology and documentation requirements efficiently. </li><li>Experience working in high-pressure environments such as Level I trauma centers or Level II trauma centers with OR experience preferred. Join us in delivering exceptional patient-centered care by leveraging your clinical expertise and passion for helping others!</li></ul>Pay: $19.00 - $22.00 per hourWork Location: In person

Case Manager

CorVel Corporation

<div>The Professional Review Specialist analyzes medical services and billing across various claim types to evaluate the accuracy of charges and the medical necessity of care provided.

This is a hybrid position until fully trained. Training will be full-time onsite.

ESSENTIAL FUNCTIONS &amp; RESPONSIBILITIES:
<ul>
<li>Identify the necessity of the review process and communicate any specific issues of concern to the claims examiner/client and or direct reporting manager</li>
<li>Collect supporting data and analyze information to make decisions regarding appropriateness of billing, delivery of care and treatment plans</li>
<li>Appropriately document work and final conclusions in designated computer program</li>
<li>Additional duties as assigned</li></ul> 


KNOWLEDGE &amp; SKILLS:
<ul>
<li>Thorough knowledge of ICD Diagnoses and Procedure Codes, and C.P.T., as well as an understanding of medical terminology</li>
<li>Knowledge of applicable fee schedule and or applicable U&amp;C Guidelines</li>
<li>Proficient in Microsoft Office applications
</li><li>Technical aptitude with the ability to expand knowledge of MedCheck&rsquo;s proprietary systems</li>
<li>Ability to work independently, follow process guidelines, and meet productivity standards and timelines (must maintain a score of 98% or higher on performance audits)</li></ul> 


EDUCATION &amp; EXPERIENCE:
<ul>
<li>Associate&rsquo;s degree or equivalent experience</li>
<li>CPC or CPC-A required</li>
<li>Previous experience in the following areas preferred:
<ul><li>Medical bill auditing</li>
<li>Knowledge of workers' compensation claims process</li>
<li>Prospective, concurrent and retrospective utilization review</li></ul></li> 
</ul>
PAY RANGE:

CorVel uses a market based approach to pay and our salary ranges may vary depending on your location. Pay rates are established taking into account the following factors: federal, state, and local minimum wage requirements, the geographic location differential, job-related skills, experience, qualifications, internal employee equity, and market conditions. Our ranges may be modified at any time.

For leveled roles (I, II, III, Senior, Lead, etc.) new hires may be slotted into a different level, either up or down, based on assessment during interview process taking into consideration experience, qualifications, and overall fit for the role. The level may impact the salary range and these adjustments would be clarified during the offer process.

Pay Range: $22.17 - $35.66 per hour

A list of our benefit offerings can be found on our CorVel website: CorVel Careers | Opportunities in Risk Management

In general, our opportunities will be posted for up to 1 year from date of posting, or until we have selected candidate(s) to fulfill the opening, whichever comes first. 


ABOUT CORVEL:

CorVel, a certified Great Place to Work&reg; Company, is a national provider of industry-leading risk management solutions for the workers&rsquo; compensation, auto, health and disability management industries. CorVel was founded in 1987 and has been publicly traded on the NASDAQ stock exchange since 1991. Our continual investment in human capital and technology enable us to deliver the most innovative and integrated solutions to our clients. We are a stable and growing company with a strong, supportive culture and plenty of career advancement opportunities. Over 4,000 people working across the United States embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).

A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.

CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.

#LI-Hybrid</div>

(Certified Professional Medical Coder) Professional Review Specialist II

CVS Health

<div>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger &ndash; helping to simplify health care one person, one family and one community at a time.
Position Summary 
Develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Aetna. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies. 
Position Summary/Mission 
Utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes. 
Fundamental Components &amp; Physical Requirements
<h3 class="jobSectionHeader">(Include but are not limited to)</h3> 
Assessment of Members<ul><li>
Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member&rsquo;s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member&rsquo;s benefit plan and available internal and external programs/services.- Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.</li><li>
Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated. Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.</li></ul>
Enhancement of Medical Appropriateness and Quality of Care<ul><li>
Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member&rsquo;s needs to ensure appropriate administration of benefits</li><li>
Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes</li><li>
Identifies and escalates quality of care issues through established channels</li><li>
Ability to speak to medical and behavioral health professionals to influence appropriate member care.</li><li>
Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health</li><li>
Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.</li><li>
Helps member actively and knowledgably participate with their provider in healthcare decision-making</li><li>
Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs.</li></ul>
Monitoring, Evaluation and Documentation of Care<ul><li>
In collaboration with the member and their care team develops and monitors established plans of care to meet the member&rsquo;s goals</li><li>
Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.</li></ul> 
Required Qualifications<ul><li>
Candidate must reside in Illinois</li><li>
Candidate must possess reliable transportation and be willing and able to travel up to 25% of the time in and around candidates home locations (Mileage is reimbursed per our company expense reimbursement policy)</li><li>
Candidate must have active and unrestricted Licensed Clinical Social Worker (LCSW)/ Licensed Clinical Professional Counselor (LCPC) in Illinois</li><li>
3-5 years of direct clinical practice experience post masters degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility
</li><li>Confidence working at home/independent thinker, using tools to collaborate and connect with teams virtually</li><li>
Excellent analytical and problem-solving skills</li><li>
Effective communications, organizational, and interpersonal skills.</li><li>
Ability to work independently</li><li>
Effective computer skills including navigating multiple systems and keyboarding</li><li>
Demonstrates proficiency with standard corporate software applications, including MS Word, Excel, Outlook, and PowerPoint, as well as some special proprietary applications</li></ul> 
Preferred Qualifications<ul><li>
Case management and discharge planning experience</li><li>
Managed care/utilization review experience</li><li>
Crisis intervention skills</li></ul> 
Education<ul><li>
Master's Degree in Behavioral/Mental Health or related field (REQUIRED)</li></ul>
License<ul><li>
Active and unrestricted Licensed Clinical Social Worker (LCSW)/ Licensed Clinical Professional Counselor (LCPC) in Illinois</li></ul>
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$66,575.00 - $142,576.00
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. 
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. 
Additional details about available benefits are provided during the application process and on Benefits Moments. 
We anticipate the application window for this opening will close on: 06/30/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</div>

Behavioral Health Clinical Case Manager - LCPC/LCSW - Illinois

Stony Brook University Medical Center

<div><div>Case Manager</div><div></div><div><div> 
</div><div>
Position Summary</div><div></div><div><div> 
At Stony Brook Medicine, a TH Staff Associate/Case Manager is a valuable member of our team, who provides clinical services to our patient population. Qualified candidates will demonstrate superior patient care and possess outstanding communication skills while adhering to our high standard of excellence.</div><div></div><div> 
Duties of a TH Staff Associate/Case Manager in the Care Management Department may include the following but are not limited to:</div><ul><li>
Completes Utilization review screen for inpatient and observation cases. Activity includes UR from the Emergency Room or on the unit to ensure guidelines are reviewed and the plan of care is discussed with the team. Works closely with the Case Managers and Social Workers on the units and reviews findings with them. Ensures that patients are placed in the correct level of care from initial assess point. Follows cases for authorization for in patient stay.</li><li>
Staff review short stay, long stay and complex cases to affect and ensure a safe discharge plan. Completes retrospective review, one and two day short stay reviews and other projects as assigned. Identifies, follows and documents Avoidable delays in Care Management Program. Reviews and documents on patients who were readmitted within thirty days. Documents over utilization of resources and services.</li><li>
All Medicare cases are reviewed for level of care on admission. Reviews with the Attending, any patient who does not meet in-patient criteria for admission. Follows the process for Code 44 on Medicare patients. Follow the process for Code 44 on all other payers.</li><li>
Active participation with the physician and payer to prevent denials. Reviews cases for potential change in level of care with the CM and physician.</li><li>
Communicates with the transferring hospital, Patient Access and physicians and payers for authorization prior to transfer from other hospitals.</li><li>
Consistent documentation in the EMR regarding acuity, plan of care and communication with the team. Charting includes data for authorization and data management.</li><li>
Reviews cases daily from admission through discharge to prevent denials.This includes patient and family contacts, insurance authorizations, tests, procedures, community resources etc.</li><li>
Assistants with coordination for discharge planning including patient and family education with the interdisciplinary team. Coordinates transitional care planning for outpatient resources, prepares PRI for early referrals and contacts with agencies and facilities throughout the hospital stay.</li><li>
Actively involved in performance improvement activities including program development, data collection and analysis.</li><li>
Maintain high level customer service.</li><li>
All unit coverage as needed and other duties as required.</li></ul><div></div><div> 
Qualifications</div><div></div><div> 
Required: A Bachelor&rsquo;s degree or a nurse working on their degree with an RN license and working history of 5 years in hospital setting. A candidate should have a good understanding of the admission/discharge process. They need good interpersonal skills to work with all team members. They need to document accurately and be able to prioritize their work and follow up with cases.</div><div>
Preferred: CM, UM, Quality, Coding, Risk or MCG Certification Working knowledge of MCG or Interqual PRI Certified Knowledge of regulatory requirements Bilingual Recent experience in tertiary care Experience in pediatrics, NICU, Mother/Baby or ED Leadership skills Master&rsquo;s prepared.</div><div></div><div> 
Please Note: Verification of degree (e.g., diploma or official transcript) is required for this role. Upload of documentation must be included with your application for consideration.</div><div></div><div> 
Special Notes: Resume/CV should be included with the online application.
Posting Overview: This position will remain posted until filled or for a maximum of 90 days. An initial review of all applicants will occur two weeks from the posting date. Candidates are advised on the application that for full consideration, applications must be received before the initial review date (which is within two weeks of the posting date).
If within the initial review no candidate was selected to fill the position posted, additional applications will be considered for the posted position; however, the posting will close once a finalist is identified, and at minimal, two weeks after the initial posting date. Please note, that if no candidate were identified and hired within 90 days from initial posting, the posting would close for review, and possibly reposted at a later date.
______________________________________________________________________________________________________________________________________ 
<ul><li>
Stony Brook Medicine is a smoke free environment. Smoking is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises.</li><li>
All Hospital positions maybe subject to changes in pass days and shifts as necessary.</li><li>
This position may require the wearing of respiratory protection, which may prohibit the wearing of facial hair.</li><li>
This function/position maybe designated as &ldquo;essential.&rdquo; This means that when the Hospital is faced with an institutional emergency, employees in such positions may be required to remain at their work location or to report to work to protect, recover, and continue operations at Stony Brook Medicine, Stony Brook University Hospital and related facilities.</li></ul> 
Prior to start date, the selected candidate must meet the following requirements: 
<ul><li>
Successfully complete pre-employment physical examination and obtain medical clearance from Stony Brook Medicine's Employee Health Services*</li><li>
Complete electronic reference check with a minimum of three (3) professional references.</li><li>
Successfully complete a 4 panel drug screen*</li><li>
Meet Regulatory Requirements for pre employment screenings.</li><li>
Provide a copy of any required New York State license(s)/certificate(s).</li></ul> 
Failure to comply with any of the above requirements could result in a delayed start date and/or revocation of the employment offer.<ul><li>The hiring department will be responsible for any fee incurred for examination.</li></ul>
 _____________________________________________________________________________________________________________________________________ 
Stony Brook University is committed to excellence in diversity and the creation of an inclusive learning, and working environment. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, pregnancy, familial status, sexual orientation, gender identity or expression, age, disability, genetic information, veteran status and all other protected classes under federal or state laws. 
If you need a disability-related accommodation, please call the University Office of Equity and Access at (631)632-6280.
In accordance with the Title II Crime Awareness and Security Act a copy of our crime statistics can be viewed here.
Visit our WHY WORK HERE page to learn about the total rewards we offer. 
Stony Brook University Hospital, consistent with our shared core values and our intent to achieve excellence, remains dedicated to supporting healthier and more resilient communities, both locally and globally.
Anticipated Pay Range:
The salary range (or hiring range) for this position is $89,760 - $127,975 Base
The above salary range represents SBUH&rsquo;s good faith and reasonable estimate of the range of possible compensation at the time of posting. The specific salary offer will be based on the candidate&rsquo;s validated years of comparable experience. Any efforts to inflate or misrepresent experience are grounds for disqualification from the application process or termination of employment if hired.
Some positions offer annual supplemental pay such as:<ul><li>
Location pay for UUP, CSEA &amp; PEF full-time positions ($4000)</li><li> 
Inconvenience pay/supplemental shift differential. ($575)</li></ul> 
Your total compensation goes beyond the number in your paycheck. SBUH provides generous leave, health plans, and a state pension that add to your bottom line.</div></div><div> 
</div></div><div>
Job Number: 2601078</div><div>
Official Job Title: TH Staff Associate</div><div>
Job Field: Other</div><div>
Primary Location: US-NY-Stony Brook</div><div>
Department/Hiring Area: Care Management</div><div>
Schedule: Full-time Shift :Day Shift Shift Hours: 8:00am - 4:30pm/ 8:30am-5pm Pass Days: Sat, Sun</div><div>
Posting Start Date: Apr 13, 2026</div><div>
Posting End Date: Jul 12, 2026, 10:59:00 PM</div><div>
Salary:$89,760 - $127,975 Base</div><div>
Salary Grade:SL4</div><div>
SBU Area:Stony Brook University Hospital</div></div>

San Ysidro Health

Position Summary: 
Reporting to the HCBA Waiver Manager, and as a member of the Care Management Team, the Social Worker supports the development and monitoring of the plan of treatment for a caseload of Home and Community Based Alternatives Waiver Program participants and provides community-based (in-home, telehealth, and telephonic) evaluation of services to ensure the health, safety, and well-being of vulnerable and high-risk populations. This includes supporting transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed by members. This position provides social services support such as participant screening, case management, counseling, and referral.
 
Essential Functions of the Job: 
<ul>
<li>Responsible for the proactive management of acutely and chronically ill patients with the objective of improving health outcomes and costs by providing the social services support critical to delivering the participant plan of treatment that reflects a comprehensive needs assessment, intervention development, and support.</li>
<li>Conducting a comprehensive health and psychosocial assessment of participants’ medical needs, diagnosis, functional and cognitive abilities, and environmental and social needs, working in conjunction with a registered nurse, to determine which service(s) are required to meet participants’ needs and preferences in the community.</li>
<li>Working with the participants, their legal representatives, circles of support, and/or primary care physicians and providers to develop an effective Plan of Treatment (POT), including:</li>
<li>Developing goals associated with the participant’s assessed needs, individual circumstances, and preferences.</li>
<li>Mitigates risk and minimizes disruptions in services.</li>
<li>Identifies when services in the POT are available through friends, family, and/or other publicly funded programs.</li>
<li>Implement the POT, including identifying service providers and community resources to help assure the timely, effective, and efficient mobilization and allocation of the services.</li>
<li>Identify (and arrange training, if necessary), backup caregivers who are willing and able to provide unpaid support if/when waiver service providers do not arrive when scheduled.</li>
<li>Provide information, education, counseling, and advocacy to, and on behalf of, participants.</li>
<li>Routine monitoring of the delivery and quality of HCBA Waiver services to ensure HCBA Waiver participants are receiving services as authorized in their POTs, including a monthly face-to-face visit or telephone call, to monitor for changes in health, mood, social integration, functionality, and overall well-being.</li>
<li>Conducting routine annual face-to-face visits for HCBA Waiver Program participants, reassessments, and care plan updates; and, following up with the participant after Emergency Department and inpatient facility admissions.</li>
<li>Develop resources and refer patients and families to appropriate community agencies or facilities, acts as liaison with such organizations and as advocate for participants.</li>
<li>Maintain accurate HCBA Waiver Program case management records and timely documentation standards.</li>
<li>Consult with and advise staff members as to the relationship of social, emotional, and cultural factors to health and medical care, and as to the availability of social services in the community.</li>
<li>Maintains a working knowledge of facility service areas including transportation, community characteristics and geography.</li>
<li>Maintains a networking liaison with other organizations to address a broad range of social service needs. May be requested to represent the agency in contact with human service, health care, and community organization groups and individuals.</li>
<li>Attending meetings, teleconferences, and trainings; or ensure a knowledgeable proxy attends in the place of the program lead to ensure the transfer the information.</li>
<li>Participates as a clinical consultant within the Homes Health Program to review and inform regarding the participants health action plan, act as clinical resource for care coordinators, as needed; and facilitate access to primary care and behavioral health providers, as needed to assist care coordinators.</li>
</ul>
Additional Duties and Responsibilities: 
<ul>
<li>Works independently and as an effective member of the interdisciplinary team.</li>
<li>Time management in regard to projects and their respective activities, timelines and issues.</li>
<li>Demonstrate ability to inter-relate with physicians, nurses, patients, internal departments, outside agencies, and the public.</li>
<li>Demonstrate customer-focused service skills.</li>
<li>Knowledge of HMO and Waiver program regulations related to eligibility requirements and plan specifics.</li>
<li>Basic physical, psychosocial, and functional assessment skills.</li>
<li>Able to collaborate between organizational and community resources.</li>
<li>Thorough knowledge of appropriate utilization of acute hospital, long-term care and home care resources.</li>
<li>Able to document concise yet thorough clinical documentation of patient assessment and care needs.</li>
<li>Demonstrated strong communication and customer service skills, problem solving, critical thinking, time management, organizational skills and clinical judgment abilities.</li>
<li>Ability to use computers as well as EHR’s.</li>
<li>Complies with all department, organization and government policies & procedures.</li>
<li>Attends meetings and training courses as required.</li>
<li>Adheres to and models SYH’s core values and behaviors of Excellence, Empowerment, Integrity and Respect.</li>
<li>Adheres to SYH attendance and punctuality policies and practices.</li>
<li>Performs other duties as assigned.</li>
</ul>
Job Requirements
 
Education Required: 
Bachelor's Degree from an accredited School of Social Work
 
Certifications/Licenses Required: 
Valid CA driver’s license, access to an insured vehicle, and ability to drive within San Diego County and possibly to Imperial County.
 
Experience and Required Skills:A minimum 2 years of any combination of the below: 
<ul>
<li>2 years of experience working in a managed care health plan or</li>
<li>2 years of experience in utilization review, case management, and/or discharge planning or</li>
<li>2 years of experience in transitional care and acute care settings (critical care, acute hospital care, long term acute care, skilled nursing care, long term care).</li>
<li>Must thrive within a team environment, possess good organizational skills, and can effectively handle difficult and unusual interpersonal situations.</li>
<li>Good knowledge of Microsoft Applications including Word, Excel, and Power Point.</li>
<li>Computer data entry, analysis and reporting experience required.</li>
<li>Knowledge of Electronic Health Data Systems including Epic preferred.</li>
<li>Demonstrated ability to be culturally sensitive and respect diversity, work effectively with individuals of different cultures and socio-economic status.</li>
<li>Passion for service.</li>
<li>Self-starter and highly organized.</li>
<li>Ability to prioritize and complete a large volume of work within strict deadlines.</li>
<li>Provide prompt, efficient and responsive customer service.</li>
</ul>
Equipment used: 
Personal vehicle, computers, phones, copy machines, fax machines and other general office equipment.
 
Working Conditions and Physical Requirements: 
<ul>
<li>Physical clearance for reaching, bending, stooping, crouching, kneeling, and grasping.</li>
<li>Have full range of motion and ability to lift up to 50 lbs.</li>
<li>T.B. clearance.</li>
<li>Frequent standing and walking indoors and outdoors.</li>
<li>Will be required to travel to other sites or other locations in San Diego County.</li>
<li>May be asked to work outside of normal business hours occasionally.</li>
</ul>
Universal Requirements: 
Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs.
 
About Us San Ysidro Health is a Federally Qualified Health Care organization committed to providing high quality, compassionate, accessible and affordable healthcare services for the entire family. The organization was founded by seven women in search of medical services for their families and community. Almost 50 years later, San Ysidro Health now provides innovative care to over 108,000 patients through a vast and integrated network of 47 program sites across the county. San Ysidro Health could not serve our patients without the dedication of our passionate and hardworking employees. Apply today and become a part of our mission-driven team! San Ysidro Health has a long-standing commitment to equal employment opportunity for all applicants for employment. Employment decisions including, but not limited to, those such as employee selection, performance evaluation, administration of benefits, working conditions, employee programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to race, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.

Medical Social Worker, BSW

Nextcare

<div>
 Medical Officer &ndash; Inpatient Precertification is responsible for managing the Inpatient Precertification cases while ensuring that departmental goals, timeline of activities, and compliance measures are met.
 
 
 
 What You Do
 
 
 
 <ul>
 <li>
 Precertification team is functional on 24/7 basis. Therefore the Medical Officer will be working on flexible shift basis as per the schedule provided by the Team Leader.
 </li>
 <li>
 Adjudicates Cases at IP precertification level, authorizes decision within the stipulated turnaround time &amp; with the highest quality standards in view with the policy terms and conditions.
 </li>
 <li>
 Performing complete file review with regards to the multidisciplinary notes, TPR charts, physician order&rsquo;s notes, lab reports, radiology reports, drug chart sheets, consultation notes, nursing notes, progress notes, etc.
 </li>
 <li>
 Requesting any medical documentation or finding any missing document which is essential in decision making.
 </li>
 <li>
 Performing review of DRG Severity of Illness (SOI) in line with revision of CPT codes / ICD codes, which are being up-coded by the provider &ndash; if required discussion with the treating doctor and the medical coders.
 </li>
 <li>
 Performing utilization review for DRG cases and FFS cases with regards to and not limited to final bill review + consumables mark ups + non covered item/services + overutilization of services.
 </li>
 <li>
 Performing review of claims as per CPT and ICD coding guidelines in line with insurance regulators (DHA,DOH/HAAD,MOH).
 </li>
 <li>
 Adhering to the cost containment protocols for medical management cases.
 </li>
 <li>
 Referring cases for second opinion when deemed necessary to confirm the best mode of management &ndash; also for cost containment to lesser Negotiating factor (NF) facilities within the member&rsquo;s network or option for home country treatment.
 </li>
 <li>
 AI READINESS Work effectively in an environment shaped by artificial intelligence (AI), machine learning, data, analytics and cloud-based tools, using insights responsibly with our standards of data governance, security and ethical use.
 
 
 </li>
 </ul>
 
 What You Bring
 
 
 
 <ul>
 <li>
 Bachelor&rsquo;s of Pharmacy / Dentistry / Medicine / Nursing / Physiotherapist / Paramedics
 </li>
 <li>
 01-02 years of Medical Practical Experience (reputable insurance provider, broker or a TPA experience a plus) OR Entry Level
 </li>
 <li>
 Physically fit to carry out duties.
 </li>
 <li>
 Certified Medical Coder [Preferable]
 </li>
 <li>
 Legally permitted to work in the country of operations.
 </li>
 <li>
 Physically fit to carry out duties.
 </li>
 <li>
 Fluency in MS Office (Excel, Word, Outlook, PowerPoint) and general internet navigation and research skills.
 
 
 </li>
 </ul>
 
 How We Hire
 
 
 
 
 
 Agency Statement
 
 Allianz Partners does not accept unsolicited CV&rsquo;s or approaches from agencies. We only work with partners on our approved supplier list, under
 
 
 contract. Any unsolicited submission will not be considered
 
 
 
 
 Key Benefits/What We Offer
 
 
 
 Allianz Partners is a world leader in B2B2C insurance and assistance, offering global solutions that span international health and life, travel insurance, automotive and assistance. Customer driven, our innovative experts are redefining insurance services by delivering future-ready, high-tech high-touch products and solutions that go beyond traditional insurance. Our products are embedded seamlessly into our partners&rsquo; businesses or sold directly to customers, and are available through four commercial brands: Allianz Assistance, Allianz Automotive, Allianz Travel and Allianz Care.
 
 
 At Allianz Partners, Artificial Intelligence (AI) is transforming service delivery and innovation. By leveraging Business Intelligence and Data Analytics, we enhance strategic decision-making and customer experiences. Our commitment to Ethical AI ensures responsible deployment, maintaining data integrity and trust. Conversational AI improves communication, while Emerging Technologies and Generative AI drive industry leadership and new opportunities. With robust Information Security Management, we protect sensitive information, ensuring compliance and security. Embrace the future of AI with Allianz Partners, where possibilities become realities.
 
 
 94031 | Customer Services &amp; Claims | Professional | Non-Executive | Allianz Partners | Full-Time | Permanent
 
 
 Allianz Group is one of the most trusted insurance and asset management companies in the world. Caring for our employees, their ambitions, dreams and challenges, is what makes us a unique employer. Together we can build an environment where everyone feels empowered and has the confidence to explore, to grow and to shape a better future for our customers and the world around us.
 
 
 At Allianz, we stand for unity: we believe that a united world is a more prosperous world, and we are dedicated to consistently advocating for equal opportunities for all. And the foundation for this is our inclusive workplace, where people and performance both matter, and nurtures a culture grounded in integrity, fairness, inclusion and trust.
 
 
 We therefore welcome applications regardless of ethnicity or cultural background, age, gender, nationality, religion, social class, disability or sexual orientation, or any other characteristics protected under applicable local laws and regulations.
 
 
 
 Great to have you on board.
 
 Let's care for tomorrow.
 
 
 Note: Having different strengths, experiences, perspectives and approaches is an integral part of Allianz&lsquo; company culture. One means to achieve this is a regular rotation of Allianz Executive employees across functions, Allianz entities and geographies. Therefore, the company expects from its employees a general openness and a high motivation to regularly change positions and collect experiences across Allianz Group.
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