- Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.
- Areas managed may include authorizing inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.
- Applies clinical knowledge to work with facilities and providers for care-coordination.
- May also manage appeals for services denied.
- Hires, trains, coaches, counsels, and evaluates performance of direct reports.
- Requires current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States. If the position is within the Government Business Division, a current active unrestricted RN license is preferred.
- Minimum of 5 years acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.
- Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills strongly preferred.
- Fully Bilingual (English & Spanish), Must be able to write, read and speak both languages in a proficiency level.
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Patient Transportation Representative
hace 5 días
Elevance Health San Juan, Puerto Rico De jornada completaJob Description · : MMM Holdings, LLC is a company that provides Medicare Advantage and Medicaid plans in Puerto Rico. Currently, MMM Holdings, LLC operates in Puerto Rico under Elevance Health, Inc. a leading health company dedicated to improving the quality of life of communi ...
Mgr I Medical Mgmt - San Juan, Puerto Rico - Elevance Health
Descripción
Job Description
:A proud member of the Elevance Health family of companies, Carelon Global Solutions, formerly Legato Health Technologies is a managed service delivery organization, providing information technology and business operations services for health plans.
Mgr I Medical Mgmt
Location: This is a virtual position, however as we have entered a hybrid workforce strategy, the candidate is required to live within the region of Puerto Rico and be able to participate in an onsite training and/or meetings on Carelon's Office Building located in PR-San Juan, 654 Ave Munoz Rivera as requested.
S chedule: This position will work a first shift but must be flexible to the US States time zones that the unit will be supporting.
The Mgr I Medical Mgmt is responsible to manage a team of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources.
How you will make an impact
Primary duties may include, but are not limited to:
Minimum Requirements:
Preferred Skills, Capabilities, and Experiences:
Job Level:
ManagerWorkshift:
Job Family:
MED > Licensed NursePlease be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact for assistance.
