- COOLSOFT (Raleigh, NC)
- …Authorizations, Drug Utilization Review (DUR) and pharmacy lock-in related processes, Behavioral health , and A+ kids, Preferred Drug List (PDL) and Medicaid ... Business Analysis Product Management Excellent Communication Skills HIPPA Speciali Requirement id... Review (DUR) and pharmacy lock-in related processes o Behavioral health , and A+ kids. o Preferred… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …a member's benefit coverage while working remotely. Primary Responsibilities * Performs behavioral health clinical utilization reviews using evidenced based ... About The Role BHPS provides Utilization Management services to its clients....* Experience with both inpatient and outpatient reviews for Behavioral Health (examples: TMS, ECT, ABA, Psychotherapy,… more
- Elevance Health (Durham, NC)
- ** Utilization Management Medical Director- NC Medicaid** Location: This role enables associates to work virtually full-time, with the exception of required ... be considered. The **Medical Director** will be responsible for utilization review case management for North Carolina...For Health Solutions and Carelon organizations (including behavioral health ) only, minimum of 5 years… more
- CenterWell (Raleigh, NC)
- …+ Experience with Home Health preferred + Previous experience in utilization management within Insurance industry a plus + Previous Medicare ... clinical experience. + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Intelligence +… more
- Humana (Raleigh, NC)
- …value-based care, quality metrics, population health , and disease or care management . The Behavioral Health Medical Director may develop procedures, ... part of our caring community and help us put health first** The Behavioral Health ...management , utilization management , case management , discharge planning and/or home health or… more
- UNC Health Care (Raleigh, NC)
- … and well-being of the unique communities we serve. Summary: A Social Worker - Behavioral Health II is an integral member of the healthcare team, providing ... **Job Details** Legal Employer: NCHEALTH Entity: Health Alliance Organization Unit: Pop Health Care Management Work Type: Full Time Standard Hours Per Week:… more
- Highmark Health (Raleigh, NC)
- …:** **JOB SUMMARY** This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and ... (DO) **Substitutions** + None **Preferred** + Master's Degree in Business Administration/ Management or Public Health **EXPERIENCE** **Required** + 5 years… more
- Elevance Health (Durham, NC)
- …to day clinical responsibilities means that the medical director is directly involved in Utilization Management and Case Management . + Daily case reviews for ... medical director provides clinical expertise in all aspects of utilization review and case management . Provides input...For Health Solutions and Carelon organizations (including behavioral health ) only, minimum of 5 years… more
- UNC Health Care (Morrisville, NC)
- …of patients based on various factors such as medical conditions, social determinants of health , and behavioral health needs. b. Develop strategies to ... **Description** UNC Health Alliance is UNC Health 's statewide...Payer Communication: a. Collaborate with payers, insurance companies, and utilization management teams to optimize reimbursement and… more
- Highmark Health (Raleigh, NC)
- …of clinical, case/ utilization management and/or disease/condition management experience, or provider operations and/or health insurance experience ... health status/severity and clinical needs; and assesses health management needs of the assigned member...first 6 months of employment. **Preferred** + Certification in utilization management or a related field +… more
- Elevance Health (Durham, NC)
- … Health OP services. + Mentors Behavioral Health Care Management staff by assisting in training, attending utilization management rounds, and ... will make an impact:** + Partners with internal UR staff and external Behavioral Health Providers to ensure appropriate and consistent utilization of plan… more
- Highmark Health (Raleigh, NC)
- …impact corporate performance + Researches, manipulates, and prepares data related to Health Management programs that document program activities and the results ... the impact of Highmark's business decisions on Informatics, personnel utilization , and the use and planning of technology. The role...of Health Management… more
- UNC Health Care (Chapel Hill, NC)
- …of patients based on various factors such as medical conditions, social determinants of health , and behavioral health needs. b. Develop strategies to ... 7. Payer Communication: a. Collaborate with payers, insurance companies, and utilization management teams to optimize reimbursement and facilitate timely… more
- Highmark Health (Raleigh, NC)
- …of internal clinical and value-based evaluation committees that drive formulary and utilization management functions. + Participate in product specific Pharmacy ... value of implemented initiatives. + Lead product based pharmacy trend management discussions with internal partners including senior executives. + Support… more
- Highmark Health (Raleigh, NC)
- …terms through regular on-site audits. Apply an active role in network management , training, monitoring and enforcement of company policies and procedures while ... confidentiality agreements. Monitor financial performance of contracts by tracking utilization and competitive environment, including group specific performance guarantees.… more
- Highmark Health (Raleigh, NC)
- …and education or if necessary involve Special Investigation Unit or the Utilization Management area. **ESSENTIAL RESPONSIBILITIES** + Implement the pre-payment ... data to assure appropriate level of payment and resource utilization . It is also used to identify issues which...measurable outcomes. Will monitor and analyze the delivery of health care services in accordance with claims submitted, and… more
- Highmark Health (Raleigh, NC)
- **Company :** Highmark Health **Job Description :** **JOB SUMMARY** This job plays a key role in ensuring projects (ie change initiatives) meet objectives on time ... and minimize risk to implementation. Works to drive faster adoption, higher ultimate utilization and greater proficiency of the changes that impact employees in the… more
- UNC Health Care (Chapel Hill, NC)
- …inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve. Summary: A Social Worker ... This includes assessing their support systems, coping mechanisms, mental health conditions, and psychosocial factors. 2. Patient-Centered Care Plans: Collaborate… more
- Elevance Health (Durham, NC)
- …Capabilities, and Experiences:** + PharmD highly preferred + Experience with behavioral health and psychiatric conditions/medications for children and adults, ... of an Extraordinary Team** CarelonRx is a proud member of the Elevance Health family of companies providing unparalleled level of service in pharmacy benefits. By… more
- City of Durham (Durham, NC)
- …meet the needs of people in crisis with compassionate care and behavioral health expertise. Interested applicants can visit our website ... Familiarity with Durham health systems and community resources/services for physical health behavioral and mental health , substance use, Intellectual… more
