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Duties/Responsibilities:
Applies clinical and critical thinking skills in evaluating the content of disenrollment requests
Communicates with the clinical teams regarding safety concerns and regulatory requirements on an ongoing basis
Proficiently uses systems and applications such as TruCare, PEGA, MHS, ePACES and CMS.
Validates content of disenrollment requests in reviewing of Uniform Assessment System (UAS) assessments, care plans, medical authorizations, and supporting documentation to ensure compliance with regulatory requirements and internal policies
Ensures disenrollments are processed within 24 hour time frame
Communicates with internal teams and external facilities and vendors for safe and successful processing of disenrollments from the plan
Maintains tracking tool to log disenrollment review results including areas of non-compliance and informing PCMs in what areas of improvement are needed for discussion with their managers as it pertains to disenrollment
Address authorizations to reflect exit date from plan
Outreaches and communicates with members and representatives as needed in reference to disenrollment status/requests
Additional duties as assigned
Minimum Qualifications:
RN, LCSW, LMSW, LMFT, LMHC, LPC, licensed psychologist (any state)
Preferred Qualifications:
Critical thinking skills with a demonstrated ability to handle rapidly changing workflow situations
Knowledge and experience with the current community health practices for the frail adult population and cognitive impaired seniors
Proficiency in TruCare, ePACES, MHS and CMS
Experience managing member information in a shared network environment using paperless database modules and archival systems
Experience and knowledge of the relevant product line
Relevant work experience preferably as a Care Manager
Demonstrated ability to multi-task and effectively work in a fast-paced environment
Proficient with simultaneously navigating the Internet and multi-tasking with multiple electronic documentation systems.
Experience usingMicrosoft Excel with the ability to edit, search, sort/filter and other Microsoft and PHI systems
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.