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- Manages the utilization of mental health and/or substance use disorder services by assessing members’ needs for services through telephone interviews, clinical documentation review, and collaboration with treating providers.
- Utilizes clinical judgement and knowledge in applying medical necessity criteria guidelines or internally derived policies to determine the medical necessity of treatment requests requiring prior authorization and concurrent review.
- Obtains accurate and detailed clinical information from appropriate sources to facilitate clinical review...
- Organizes information from members’ health history and internal data sources to develop an outreach approach to address member needs.
- Implement interventions with members and their providers/supports.
- Documents member information and contacts made regarding member’s care and services provided.
- Reviews, monitors, and updates quality program plans, materials and reports.
- Actively...
- Conduct medical necessity reviews and determinations of prior authorizations and referrals, including reviews of previously denied and appealed decisions
- Oversight and day-to-day management of a team of Associate Medical Directors, including performance management, timekeeping, and managing the MD calendar to ensure adequate coverage during business hours and ad hoc
- Provide clinical strategy and physician input to various Clinical Services departments, including: Utilization Management, Care Management,...
- Perform audit so that errors or process issues not identified by the departments audited, are identified during quality audits.
- Ensure all findings impacting external customers are identified and corrected to improve customer experience. Document findings accurately to support all audit observations to withstand critical scrutiny.
- Complete root cause analysis by reviewing findings and formulate recommendations to mitigate future risk of trends.
- Establish complex audit plans to effectively identify and mitigate...
- Project & Operational Support
- Takes the lead on driving all software licensing renewals (including Microsoft and enterprise agreements) and oversees order/invoice processing.
- Serves as a liaison between IT and Finance for Budget forecasting and monitoring financial records, ensuring that the company follows industry (IT and healthcare) and business rules.
- Leads IT audits by gathering and analyzing data and providing recommendations to improve processing and mitigate...
- Data Modeling & Architecture
- Lead the design and development of Data Models. Create and maintain robust, scalable, and efficient logical and physical data models that support business intelligence, reporting, and advanced analytics within the health insurance domain.
- Build and maintain data transformation pipelines within the analytics environment of the enterprise data warehouse.
- Ensure that existing data models are continuously optimized for performance, scalability, and integration with evolving business...
- Lead the preparation and review of all financial statements and disclosures in accordance with GAAP, statutory requirements, and regulatory guidelines.
- Oversee the design and implementation of financial reporting systems and processes, ensuring efficiency and compliance.
- Manage the annual audit process and serve as the primary liaison with external auditors.
- Collaborate with cross-functional teams to provide financial insights that drive business decisions.
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- Translate data movement needs into technical ETL designs.
- Map source systems to logical and physical data models.
- Monitor and take appropriate steps to maintain integrity of the data warehouse databases including content, security, and privacy issues.
- Identify opportunities for improving efficiency and/or effectiveness of processes and controls.
- Work closely with Data Warehouse Team to develop conceptual, logical, and physical data models as needed to meet...
