To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Performs treatment authorization review to determine medical necessity, appropriateness of services, and interpret benefits and limitations. Reviews that care is consistent with the Plan's standards of quality. Participates in concurrent review activiti

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Follow established Health Plan policies and procedures and use available resources such as provider contracts, Medicare and/or Medi Cal guidelines and Member Evidence of Coverage (EOC) to review, research, and adjust provider claims disputes. Coordinate

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Develop strategies, and provide direction, resources and support for department staff in coordinating NMT and NEMT transportation services to ensure members receive appropriate transportation services in a timely manner. Manage the team who work directl

To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. Comprehensive understanding of capitation models in order to setup within our core system to support multiple delegate contracts averaging approximately 50 million dollars in monthly capitation payments, based on accurate setup and configuration. Compre

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Maintain a working knowledge of SCFHP's provider network structure and contracting relationships and apply to day to day management of the information contained in the core operating/claims system. Update and maintain SCFHP's core operating/claims syste

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Complete data entry for Medicare paper applications; complete workflow tasks for all Medicare enrollment and disenrollment requests (including for applications received via mail, the Medicare Online Enrollment Center, auto and facilitated web based subm

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. On a daily basis, receive, review and arrange member requests for transportation. Communicate with the transportation vendor(s) regarding schedule availability. Follow established guidelines and resources to respond to members, providers and health plan

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Act as the primary point of contact and liaison for SCFHP members and providers contacting the plan regarding general inquiries, concerns or requests for information. Develop a general understanding of all member facing materials, communications and int

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Collect and track all information needed to complete and submit regulatory state and federal reports in a timely manner. Assist in the preparation of regulatory filings, including collection, tracking, and maintenance of all information necessary to com

To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. Maintain existing and develop new applications to support organizational business needs. Utilize data analysis techniques and queries to support internal business functions through the generation of reports. For the Application Developer III this also i

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. 1. Build and maintain positive working relationships with staff, residents, community partners and governmental agencies; form and foster partnerships with safety net and community organizations, and with government agencies. 2. Act as liaison with comm

To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. Business Systems Analyst I Project and task management for small scale projects including facilitate stakeholder and project team meetings, track actionable items, send regular project communications to team members and stakeholders, and escalate identi

To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. Develop, implement and manage all UM processes for continuous and sustained compliance with all applicable state, federal and NCQA regulatory requirements, SCFHP policies and procedures and general business requirements for all lines of business. Develo

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Read, interpret and implement all regulatory guidance related to the handling of appeals and grievances, including the Medicare Managed Care Manual, State and Federal contracts , APLs,DPLs and other memos that provide direction. Demonstrate a solid unde

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Responsible for revenue and cost reconciliation activities using capitation invoices, eligibility files, claims and expense data and other relevant reports. Design and prepare reports that analyze the financial outcome of programs and make recommendatio