FULL_TIME

FEED

OTHER

This leader will collaborate with data management to utilize predictive and prescriptive analytics to stratify our beneficiary population for inclusion in multiple Medical Management programs; direct staff and interventions that will improve beneficiary health outcomes including HEDIS scores; develop and implement clinical programs to optimize Condition/Disease Management strategies and goals; and collaborate with leadership to enhance the overall healthcare education and knowledge of our beneficiaries using multiple platforms and experiences. Technical Skills: Advanced knowledge of managed care principles; working knowledge of medical necessity review criteria, LOS, ICD, CPT, HCPCs and American Dental Coding required; quality management training/experience; extensive experience with relational databases and statistical analysis.

TriWest Healthcare Alliance

Director, Population Health

equestftpin

Technical Skills: Thorough knowledge of policies and procedures, knowledge of managed care principles and methods; medical terminology; proficiency in the application of clinical criteria: InterQual, International Classification of Diseases, Diagnostic and Statistical Manual of Mental Disorders, current Procedural Terminology, and Healthcare Common Procedural Coding System, and American Dental codes; working knowledge with medical management systems; proficient with Microsoft Office; knowledge of UM Process; reporting techniques. • Prepares work schedules and monitors staff caseloads to ensure adequate staffing levels at all times and accurate data entry and application of the medical management system.

Supervisor, Utilization Management

Medicaid, Medicare, TRICARE, VAPC3), and the insurance industry; skill in diplomacy and negotiation; skill in financial analysis to analyze contractual reimbursement; skill in project management; skill in presentation; proficient with Excel. Develops hospital, physician and ancillary service agreements, ensures adherence with government operational manuals, monitors network shortfalls, and resolves access issues throughout the assigned region.

Direct Contracting Manager

Complies with the Veterans Affairs Community Care Network (CCN) and TRICARE T-5 contracts; DHA and TRICARE program guidelines and pertinent Federal regulatory requirements; assists supervisors with FWA trending and reporting requirements; coordinates and assists with investigations and prosecutions by federal agencies interfaces directly with Veterans, Military members and family (as warranted), providers, subcontractors, and other TriWest departments on FWA issues; assist supervisor with the education and training of TriWest, subcontractor, and provider personnel on current FWA matters; prepares appropriate responses to provider compliance issues and complaints referred to Program Integrity by other TriWest departments or external referrals. The PI Investigator t is responsible for the identification, analysis, case development, and reporting of suspected fraud, waste and abuse (FWA) cases as defined by the Department of Veterans Affairs (VA), the Healthcare Finance Administration (HCFA) and the Department of Defense, Defense Health Agency for the TRICARE program; requests and reviews issue-related medical claims and records for FWA and/or administrative and clerical error(s).

Program Integrity Investigator

UNKNOWN

Global Elite Empire Consultants is a third-party recruiter, not an insurance agency) We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses and identifying potential inconsistencies or verification signals in application materials based on available information. 4. Help Others: Use your skills and expertise to assist families in securing their financial futures, providing them with the support and guidance they need to navigate life’s uncertainties with confidence.

AO Garcia Agency

Stop Building Someone Else's Dream - Remote Opportunity

sourcestack_via_bold

Maxion Research invites people in Charleston, SC to join an online research panel and be considered for optional surveys, interviews, focus groups, and product-feedback studies. Research activities may include completing online questionnaires, joining remote discussions, testing concepts, or sharing opinions about products and services.

Maxion Corp

Online Research Panel Participant - Charleston, SC

With our proprietary Ultrasound-on-Chip technology, we're democratizing healthcare by shifting ultrasound from the expensive, stationary systems of the past to the connected, mobile, and software-enabled platforms of today. Immediately reporting any suspected or actual security incidents, including phishing attempts, malware infections, or unauthorized access, following the established incident response procedure.

Butterfly Network

Regional Vice President I, Sales - Southeast

GreenHouseAPI

Maximus compensation is based on various factors including but not limited to job location, a candidate's education, training, experience, expected quality and quantity of work, required travel (if any), external market and internal value analysis including seniority and merit systems, as well as internal pay alignment. - E xperience across the Air Force and Space Force Military Departments and CYBERCOM, with demonstrated experience comprised of technical operational, sales, proposals and capture management within those organizations is required.

MAXIMUS provides business services to help governments operate health and human services programs, mostly at the state and national levels. The company's health services segment offers outsourced program management and administrative services,

Maximus

Senior Director - Capture (Air Force & Space Force)

Maximus compensation is based on various factors including but not limited to job location, a candidate's education, training, experience, expected quality and quantity of work, required travel (if any), external market and internal value analysis including seniority and merit systems, as well as internal pay alignment. If you require assistance at any stage of the employment process-including accessing job postings, completing assessments, or participating in interviews,-please contact People Operations at applicantaccom@maximus.com .

Sr. Project Management Analyst

IRecruitee

In support of TRICARE beneficiaries enrolled in the Autism Care Demonstration (ACD), the Autism Services Navigator (ASN) collaborates and oversees the assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services for TRICARE beneficiaries diagnosed with autism spectrum disorder (ASD). • Current unrestricted licensure in an appropriate state or territory of the United States, as a Licensed Independent Clinical Social Worker (LICSW), Licensed Clinical Social Worker (LCSW), Registered Nurse, or other licensed mental health professionals who possess a Certification in Case Management (CCM).

Autism Services Navigator

This work includes data entry and task processing in medical management and customer relationship management (CRM) systems, and making and receiving telephone calls, including participation in outreach campaigns. The Healthcare Operations Specialist provides non-clinical support to TriWest healthcare operations teams, supporting the access to care our military community deserves.

Healthcare Operations Specialist- HI

Orders/receives medical records for Potential Quality Issues (PQI and CQM Department activities according to desk procedures, conducts follow-up telephone calls to providers, and completes other processes to resolve missing documents. Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources.

Clinical Quality Support Specialist

Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources. The position collaborates to ensure relevant analysis and complete, timely reporting is provided to meet TriWest business needs and Government's Healthcare requirements.

Business Analyst Sr

Ensures accuracy and completion of authorization data from customer information, medical records, referral/authorization forms, Military Treatment Facility electronic transmission and other documents into medical management system. Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.

Senior Referral Specialist

Lead Referral Specialist

Performs clinical research necessary to establish evidence-based clinical content guidelines, uses technical and medical writing capabilities to create content to support targeted population campaigns, population wellness portals and activity, support accreditation and contractual requirements, beneficiary educational and other work as needed. • Supports Medical Management projects and non-clinical resources such as project managers as a subject matter expert in evidence-based clinical criteria for building assessments, care plans, interventions and other clinically-based tools and programs.

PH Communications Specialist

Referral Specialist

Technical Skills: Knowledge of TRICARE program and benefits; managed care program concepts and health care delivery processes; management reporting tools and medical management systems; legal, regulatory requirements, and HIPAA privacy regulations. Under the direction of the Director of Referral Management, the Manager will lead and guide non-clinical staff in processes that maintain accuracy, efficiency, and timeliness for all network and military referral requests.

Manager, Referral Management

Maximus compensation is based on various factors including but not limited to job location, a candidate's education, training, experience, expected quality and quantity of work, required travel (if any), external market and internal value analysis including seniority and merit systems, as well as internal pay alignment. - Work as an integral part of the capture and proposal team, assisting in the development of competitive pricing strategies, developing scoring sensitivity analyses, projecting competitive behaviors, identifying risks, and interpreting solicitation requirements.

Principal Analyst - Senior Pricer

Exercising sound judgment with minimal direction, you will lead complex risk and compliance engagements, guiding clients toward stronger security postures, delivering polished, timely, well-documented findings. As a Senior Security Advisor at Soteria, you will bring seasoned GRC expertise to a fast-paced team serving a growing roster of clients navigating today's threat landscape.

Work From Home Jobs in Summerville, SC

Director, Population Health TriWest Healthcare Alliance

Supervisor, Utilization Management TriWest Healthcare Alliance

Direct Contracting Manager TriWest Healthcare Alliance

Program Integrity Investigator TriWest Healthcare Alliance

Stop Building Someone Else's Dream - Remote Opportunity AO Garcia Agency

Online Research Panel Participant - Charleston, SC Maxion Corp

Regional Vice President I, Sales - Southeast Butterfly Network

Senior Director - Capture (Air Force & Space Force) Maximus

Sr. Project Management Analyst Maximus

Autism Services Navigator TriWest Healthcare Alliance

Healthcare Operations Specialist- HI TriWest Healthcare Alliance

Clinical Quality Support Specialist TriWest Healthcare Alliance

Business Analyst Sr TriWest Healthcare Alliance

Senior Referral Specialist TriWest Healthcare Alliance

Lead Referral Specialist TriWest Healthcare Alliance

PH Communications Specialist TriWest Healthcare Alliance

Referral Specialist TriWest Healthcare Alliance

Manager, Referral Management TriWest Healthcare Alliance

Principal Analyst - Senior Pricer Maximus

Senior Security Advisor - GRC Soteria

Similar Job Searches

Stand out to leading employers.