Assess, plan, and implement care strategies that are individualized by patient and directed toward the most appropriate, lease restrictive level of care Utilize both company and community based resources to establish a safe and effective case management plan for members Collaborate with patient, family, and healthcare providers Identify and initiate referrals for social s

Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements Engage with requesting providers as needed in peer to peer discussions Be knowledgeable in

The KA Field Account Manager is accountable for the field based service of small to mid size, standard/non standard customers under 1,000 members. In this position, the KA Field Account Manager is responsible for the following Acts as a strategic partner and consultative resource to the customer, responsible for the customer's total service experience Meets with customers

Compiles financial statements for various Management and Labor customers in prescribed formats by collecting financial data from Peoplesoft General Ledger and other finance data repositories while ensuring accuracy and consistency Prepares standard daily and month end journal entries pertaining to revenues and expense, reclassification entries and month end reconciliation

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, at least restrictive level of care Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact

Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements Engage with requesting providers as needed in peer to peer discussions Be knowledgeable in

Strategic Planning In partnership with key stakeholders across marketing, oversees the strategic planning, budget and execution of industry programs and trade shows Trade show SME Support team and partner across marketing and sales stakeholders by being the subject matter expert on trade shows, enabling capabilities, proactively meeting their needs, communicating effectiv

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Assess complaints of alleged misconduct received within the Company Investigate low to medium 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

Promote Excelsior's product portfolio to benefits brokers and help them increase their enrollment and average case size with all product lines Ability to negotiate and close sales Conduct in depth market presentations for brokers and employers Create and drive strategies for top producing agencies and Brokers Collaborate with Sales Management regarding pipeline, persisten

Administration of Pension Benefits Collection of data from pension participants to determine eligibility and vesting schedule. Answer questions via telephone and email to convey information regarding the provisions of the pension plans. Create various types of members or employer correspondence including letters and emails. Collection and data entry of participant hours w

Build and maintain solid relationships with key brokers and others as necessary within the assigned territory Develops action plans and strategies to optimize Medicare sales Partner with peers and the Sales Director (SD) to identify and develop relationships with individuals and organizations that influence the buying behavior of our target consumer (e.g., Providers, Regu

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

Make determinations of medical necessity/clinical appropriateness of treatment Assist in the development and implementation of clinical policy, guidelines and applications Regularly contact providers whose treatment determinations indicate a trend that varies with their peers and community Be knowledgeable on and apply all necessary regulatory requirements for assigned re

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