Evaluates new and on going claims to determine compensability and liability, giving consideration to contract provisions, disability management duration contract guidelines, medical evidence and vocational evidence. Investigates questionable claims. Determines needs for additional medical information. Determine appropriate benefit calculations and payments. Performs revie

Sales representative for the UHC Key Accounts responsible for broker and direct sales to customers in the 100 5000 employee range. The principle focus is the sale of new fully insured and self funded business with indirect responsibility for the retention of existing accounts New Business Sales Identifies potential healthcare business customers Accountable for prospect fr

Work collaboratively with the interdisciplinary care team, specifically external entities such as OhioRise, Care Management Entities, and Provider Practices; to ensure an integrated team approach Engage members either face to face or over the phone to assist with closing gaps in care, linking to necessary services and providing education about their health Review availabl

Serve as business counsel for the Optum Technology organization Provide legal support for transactional matters, such as software licenses, cloud computing arrangements, collaboration and joint development agreements, supply agreements, equipment purchase and lease agreements, mobile app development agreements, offshore sourcing arrangements, and IT services agreements Ne

Make outbound calls to assess members' current health status Identify gaps or barriers in treatment plans Provide patient education to assist with self management Interact with Medical Directors on challenging cases Coordinate care for members Make referrals to outside sources Coordinate services as needed (home health, DME, etc.) Educate members on disease processes Enco

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, at least 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

Answer incoming phone calls from prospective members, identify the type of assistance and information the customer needs with the goal to convert caller to a qualified lead and sale Follow up with members on questions or to review current or new products and services Navigate multiple computer systems to document member information while maintaining active listening and e

Serve as primary care manager for high medical risks / needs members with comorbid behavioral health needs Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic (SDoH) needs Develop and implement individualized, person centered care plans inclusiv

Addresses the total patient, inclusive of medical, psychosocial, behavioral, cultural, and spiritual needs Involves the individual patient and caregiver, as appropriate, in decision making Facilitates communication and coordination among members of the care team Provides patient care to include patient assessment prior to physician's/nurse practitioner's examination, serv

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 appeals are in response to adverse determinations for medical services related to benefit design and coverage and the application of clinical criteria of medical policies Perform Department of Insurance/Department of

Consult with users and technology specialists to define business processes and be the liaison between the two parties Perform Business Analysis Ability to define project objective, scope, write business and technical requirements Business Liaison to refine business requirements Communicate and validate requirements with stakeholders Validate solution meets business needs

Provide day to day paralegal and legal services support including leading or assisting on special projects from the Legal Team Work closely with Legal, Quality Management and Regulatory Affairs (QMRA), Compliance and other cross business and functional stakeholders on activities related to enterprise wide regulatory and quality management systems, including coordination,

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Assess, plan, and implement care strategies that are individualized by patient and directed toward the most appropriate, least 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 Co

Serve as primary care manager for high medical risks / needs members with comorbid behavioral health needs Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic (SDoH) needs Develop and implement individualized, person centered care plans inclusiv