mcs

Regular Exempt GENERAL DESCRIPTION: Responsible for overseeing the operations and performance of the Call Center team, ensuring efficiency, regulatory compliance, and adherence to company service standards, including the policies and procedures established by the Centers for Medicare and Medicaid Services (CMS) and other regulatory entities. ESSENTIAL...

Regular Exempt GENERAL DESCRIPTION: Conducts prospective reviews (preauthorization’s) of items or services provided to beneficiaries using the Clinical Guidelines criteria for assessing medical necessity. Determines the appropriate level of care according to the severity of the subscriber’s condition. Ensures the appropriate use of healthcare...

Regular Non-Exempt GENERAL DESCRIPTION: Responsible for resolving service cases received from various sources, including email, voicemail, fax, and internal referrals, that are processed according to established operational procedures and service guidelines to ensure the continuity of services offered by Customer Service. Handles phone calls from members...

Regular Non-Exempt GENERAL DESCRIPTION: Responsible for receiving, registering, and forwarding requests for organizational determination and/or any associated clinical documentation or documentation for the clinical management of the insured. Works with the authorizations of services that are already predetermined through the automatic process using the...

Regular Non-Exempt GENERAL DESCRIPTION: Serves as a subject matter expert responsible for overseeing enrollment and eligibility processes, ensuring compliance with federal, state, and organizational guidelines. Supports operational excellence through advanced analysis, quality assurance, training, and process improvement initiatives. ESSENTIAL...

Regular Exempt GENERAL DESCRIPTION: Evaluates utilization in clinical records and hospital facilities concurrently and retrospectively. Identifies and refers to other clinical departments (Case management, condition management, among others) cases for the management of treatment alternatives. Makes efforts to receive advice in difficult situations in...

Regular Exempt GENERAL DESCRIPTION: The Clinical Operations Monitoring Analyst is responsible for monitoring operational and regulatory processes to ensure compliance with applicable requirements, quality standards, and organizational policies. Supports operational excellence through data analysis, performance monitoring, reporting, process improvement...

Regular Exempt GENERAL DESCRIPTION: Responsible for providing a variety of tasks that guide and position data-intensive projects/programs for success. This is accomplished by understanding data requirements, coordinating work across IT, and ensuring resources are following appropriate practices and enterprise standards. This role may also be tasked to...

Regular Exempt GENERAL DESCRIPTION: The Events and Promotions Executive is responsible for handling and coordinating the logistics of Classicare events and activities and the efforts and initiatives related to the Advantage line of business. Identifies and develops work plans for region-level initiatives and provides recommendations to strengthen...

Regular Exempt GENERAL DESCRIPTION: Responsible for overseeing the implementation, administration, and continuous improvement of clinical and quality pharmacy programs within the Pharmacy Department. These programs include Medication Therapy Management (MTM), Drug Management Programs (DMP), CMS STARS initiatives, pharmacy utilization programs, academic...

Position We are looking for a Java software engineer to join the CDC team and take part in the implementation of ground segment software for European space missions. The successful candidate will work in a small, senior, hands-on team. Responsabilities involve writing production Java, reviewing...

Company Description Movu Robotics Innovation, ambitious growth, technology, state-of-the-art robots – that’s Movu Robotics in a nutshell. Due to the in-house design and manufacturing process of our systems, an exciting, hands-on work environment with plenty of challenges and advancement opportunities is guaranteed. Will you help shape the future of...

Regular Exempt GENERAL DESCRIPTION: Analyzes, investigates, supports, and answers Grievances, Dental Pre-Service, and Payment Appeals filed by members, insureds, Providers, and/or Non-Part Providers within the time stipulated contractually for both Lines of Business (LOB)and following the terms stated in the contracts established and the rights of...

Regular Non-Exempt GENERAL DESCRIPTION: Analyzes, processes, and adjudicates all types of complex claims submitted in Centers for Medicare and Medicaid Services Form 1500 (CMS‑1500) and Uniform Billing Form 04 (UB‑04) formats, applying the highest level of analytical judgment to determine appropriate payment or denial. This includes the evaluation of...

Regular Exempt GENERAL DESCRIPTION: Provides education to internal and external clients on operational topics that promote efficiency in the process executed by our providers and business partners, such as the Risk Adjustment payment model “CMS-HCC”, ensuring best practices in coding standards and clinical documentation within the medical records and...

Regular Exempt GENERAL DESCRIPTION: The Health Educator is responsible for designing and implementing educational interventions aimed at preventive care, healthy lifestyles promotion and condition management aligned with the goals and objectives of the company’s Wellness Program. ESSENTIAL FUNCTIONS: Design and develop individual and group educational...

Regular Exempt GENERAL DESCRIPTION: Responsible for the ongoing monitoring of all elements of the Special Needs Plan Care Coordination (SNP-CC) as needed to comply with regulatory requirements and quality indicators. Evaluates care coordination frameworks, identifies risks and improvement opportunities, supports audit readiness, and works closely across...

In deze veelzijdige functie ondersteun je sales- en technische collega’s met jouw productkennis en technische expertise. Daarnaast draag je actief bij aan de ontwikkeling, positionering en introductie van innovatieve communicatieoplossingen. Over Abiom Abiom Communication Systems maakt deel uit van de Mission Critical Solutions Group (MCS...

Regular Exempt GENERAL DESCRIPTION: Responsible for seeking out new prospects to present the company's products and ensuring appropriate follow-up until the sales cycle is completed, to meet the company's established goals. Research and stay updated on new trends within the industry and commercial sales processes. ESSENTIAL FUNCTIONS: Identify and...

Regular Exempt GENERAL DESCRIPTION: Responsible for presenting products to prospects and ensuring thorough follow-up until closing the sales cycle to meet company goals. Prepare accurate sales reports to document the sales process. ESSENTIAL FUNCTIONS: Identify potential clients and market segments for expanding the company's business...