Serves as primary care manager for members with primary high behavioral needs members Engage members through a variety of modalities (telephonically) to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, socioeconomic and SDOH needs Develops and implements individualized, person centered care plans inclusive of go

The Appeals and Grievances Medical Director is responsible for ongoing clinical review and adjudication of appeals and grievances cases for UnitedHealthcare associated companies. Performance accountabilities include Perform individual case review for appeals and grievances for various health plan and insurance products, which may include PPO, ASO, HMO, MAPD, and PDP. The

The UnitedHealthcare Community Plan of DC proudly serves the Dual Eligible Special Needs (D SNP) population in the District of Columbia and is excited to recruit for our leader of clinical oversight. This individual contributor will report directly to the Executive Director and will support them on coordinating select priorities, as well as have accountability in two key

Develop, lead and execute category management strategies, conduct sourcing / RFX events, manage suppliers and conduct financial analysis Primary responsibilities surround Pharmaceutical Draft, Review, and lead negotiations of third party supplier contracts, including Master Services Agreements (MSAs), Statements of Work (SOWs), Non Disclosure Agreements (NDAs) and amendme

Intake/screening/referral, assessment/reassessment, development of support plans, on going case management, monitoring of the Member's health and welfare, documentation of contacts and case management activities in the Department prescribed system, resource development, and case closure Respect confidentiality and maintain confidences as described in the UHG Employee Hand

Investigate medium to highly complex cases of fraud, waste and abuse Detect fraudulent activity by members, providers, employees and other parties against the Company Develop and deploy the most effective and efficient investigative strategy for each investigation Maintain accurate, current and thorough case information in the Special Investigations Unit's (SIU's) case tr

Sending correspondence to members Reconciling reports Performing basic data entry functions with proficient PC skills including but not limited to Microsoft products and Quickbooks Analytical and Researching techniques Initiate and assist with developments / changes to increase or change quality and productivity Preparing, processing, and maintaining new member or group e

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, lease restrictive level of care Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact Com

Assess, plan, and implement care strategies that are individualized by patient and directed toward the most appropriate, least restrictive level of care Utilize the NYS UAS Assessment as needed in the home or via telehealth to develop a person center service plan to meet the member's needs Identify and initiate referrals for social service programs, including financial, p

Assess and create a discharge plan to ensure patient receives quality medical care. Implement care strategies that are individualized for patients and directed toward the most appropriate and the least restrictive level of care Utilize both company and community based resources to establish a safe and effective case management plan for hospitalized members and effective d

Resolves provider issues Act as SME for Home and Community Based Services providers within the health plan Assist in efforts to enhance ease of use of physician portal and future services enhancements Contribute to design and implementation of programs that build/nurture positive relationships between the health plan, providers, provider administrative staff and practice

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Engage members telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medication management and me

Working across multiple platforms with ease. Taking ownership of large features and experiences and communicating design vision effectively Partnering with research and strategy teams to translate user needs into usable design improvements Advocating for the user and anticipating their needs through insights and feedback Being a trusted design partner in a cross functiona

Ability to work on sensitive subject matter with the highest level of discretion. Review and approve or deny PTO requests as well as track PTO. Responsible for updating the IEX schedules for all PTO including unscheduled absences (Phone Team only) Assist direct Manager/Supervisor in yearly annual reviews. Balance customer assignments within the team to ensure service leve