Engage members face to face and/or 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, medicati

Accountable for customer (employer) loyalty and satisfaction, as measured by survey results and persistency Establish, cultivate, and manage the customer relationship at multiple levels, serving as a healthcare consultant and trusted business advisor to these customers Establish, cultivate, and manage relationships with consultants and brokers, recognizing the value they

Customer retention, based on established annual goals Strategic planning for multi year initiatives to identify opportunities to better manage healthcare trends Responsible for communicating and managing escalated issues and problem resolution as appropriate Maintains appropriate documentation including action plans, meeting notes, Strategic Customer Business Plans, Sales

Maintenance and enhancement of existing EDI solution built on EDI Fabric in C# Troubleshoot and resolve EDI technical issues, including diagnosis and root cause analysis Troubleshoot claim workflow issues from EDI intake through EDI export Develop and maintain monitoring tools to ensure EDI connectivity meets service level agreements Analysis and design of systems and con

Analyze and report on financials Assist in the development of program forecasts, budgets, and plans Research economic progressions to assist with the organization's financial planning Create annual budget templates Prepare spreadsheets to effectively show financial results and financial forecasts You'll be rewarded and recognized for your performance in an environment tha

Review applications, gather data, determine eligibility and compliance Process broker and agent licensing, appointment and contracting credentials for Medicare Supplement Products Ensure that all paperwork, credentials and other necessary documents are in good order Perform analysis of submitted material for completeness and accuracy, analyzing, credentials and documentat

Develop key internal and external relationships to facilitate results. Understand and create a strategy based on analysis and reporting of sales and market trends, including sales plan execution, competitive intelligence and new product requirements Drive the development of market sales strategies and value proposition formulation Lead as an expert in our national account

Perform initial and ongoing reviews pertaining to primary role (PA, ICM, DCM, PACM), appropriately applying clinical criteria (InterQual, policies, National and Local Coverage Determinations) for approval and sending to Medical Directors if review is necessary for determining an adverse determination Collaborate with Medical Directors, clinical peers and Health Plan partn

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connect

Demonstrate understanding of relevant organizations' operations, products, applications, strategies and processes to effectively support Quality Reporting Operations using relevant tools and applications Submission of the NCQA Health Plan Roadmap General Information, Appendix and Attestation Submission of the NCQA Healthcare Organization Questionnaire (HOQ) Complete admin

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 t

Manage administrative intake of members Work with hospitals, clinics, facilities and the clinical team to manage requests for services from members and/or providers Process incoming and outgoing referrals, and prior authorizations, including intake, notification and census roles Assist the clinical staff with setting up documents/triage cases for Clinical Coverage Review

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 t

Lead and manage implementation process for new and in force customers with a focus on supporting our National Account, larger Key Account and Leave Management business segments Drive and develop a customized implementation plan for each account; initiate and lead projects to identify and resolve implementation transition issues specific to each client Serve as point perso

Field inbound calls in a queue from members and providers for purpose of assessment and triage Focus on initial inpatient admission for psychiatric and chemical dependency patients Make patient assessments and determining appropriate levels of care Participate in member crisis calls Determine if additional clinical treatment sessions are needed Manage inpatient mental hea