Position Summary:
The Health Professional 3 conducts utilization review, and/or telephonic customer care; problem resolution, follow up and further related services for patients and members. This key individual focuses on member engagement, education, and empowerment, establishing recommendations that manage chronic health conditions and are conductive to healthier lifestyles. Must be available while non-clinical staff performs initial screening.
Essential Functions:
Provides telephonic and/or in person health coaching and consultation for participants and members, while meeting company policies and procedures. Verifies and documents member eligibility for services. Investigates, reviews, and maintains data related to treatment, care and/or related services and identifies barriers that could affect or interfere with treatment effectiveness or adherence. Performs triage and urgent clinical risk assessment, clinical expert consultation, short-term problem resolution, clinical emergency or urgent services coordination, referral and/or follow up for members seeking services, as needed. Participates in organization determinations for either Inpatient or Partial Hospitalization cases including pre-certification and concurrent reviews, while discussing clinical/medical necessity concerns within house Physician Advisor, as needed. Collaborates with other professionals to obtain better treatment results and overall care. Communicates and interacts via “live” encounters with providers to facilitate and coordinate the activities of the Utilization Management process. Verifies and adjusts Census reports for all Inpatient/Partial Hospitalization facilities, conducts concurrent and retrospective reviews while meeting company policies and procedures. Collaborates with facilities in the Discharge planning. Completes Discharge summary using the clinical information provided by facilities at case closure. Generates authorization numbers for payment purposes, for all Inpatient or Partial services as determined in the review process. Applies APS authorization process (Milliman standards, policies, procedures, and contractual agreements) to submitted information. Authorizes services in accordance with medical and health guidelines. Coordinates with the referral source if there is not sufficient information available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows process for requesting additional information. Provides timely verbal/email/fax organization determinations to the requesting provider and/or members as per policy. Submits appropriate documentation/clinical information to clerical support for record keeping, mailing notifications and documentation requirements. Recognizes opportunities for referrals to Behavioral Health Case Management and refers accordingly. Identifies quality concerns through the review process and refers them to Quality Department for further investigation.Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS), NCQA, URAC and guidelines set forth by other regulatory agencies & HIPAA where applicable; obtains necessary professional and continuing education required for licensure and any applicable certifications. In addition, all other duties assigned by the manager and/or supervisor.Education:
Master’s Degree in a Behavioral Health field or bachelor’s degree in Nursing. Current, unrestricted clinical license(s) to practice in Puerto Rico territory.Experience:
Minimum 2 years of experience in a Clinical, Behavioral or Managed Care field preferred.Knowledge:
Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.Strong knowledge in behavior principles, chronic illnesses, and disease management. Strong telephonic assessment and customer service skills.Knowledge in community-based resources.Knowledge in clinical assessment and crisis intervention.Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum. Read LessPosition Summary:
The Health Professional 3 conducts utilization review, and/or telephonic customer care; problem resolution, follow up and further related services for patients and members. This key individual focuses on member engagement, education, and empowerment, establishing recommendations that manage chronic health conditions and are conductive to healthier lifestyles. Must be available while non-clinical staff performs initial screening.
Essential Functions:
Provides telephonic and/or in person health coaching and consultation for participants and members, while meeting company policies and procedures. Verifies and documents member eligibility for services. Investigates, reviews, and maintains data related to treatment, care and/or related services and identifies barriers that could affect or interfere with treatment effectiveness or adherence. Performs triage and urgent clinical risk assessment, clinical expert consultation, short-term problem resolution, clinical emergency or urgent services coordination, referral and/or follow up for members seeking services, as needed. Participates in organization determinations for either Inpatient or Partial Hospitalization cases including pre-certification and concurrent reviews, while discussing clinical/medical necessity concerns within house Physician Advisor, as needed. Collaborates with other professionals to obtain better treatment results and overall care. Communicates and interacts via “live” encounters with providers to facilitate and coordinate the activities of the Utilization Management process. Verifies and adjusts Census reports for all Inpatient/Partial Hospitalization facilities, conducts concurrent and retrospective reviews while meeting company policies and procedures. Collaborates with facilities in the Discharge planning. Completes Discharge summary using the clinical information provided by facilities at case closure. Generates authorization numbers for payment purposes, for all Inpatient or Partial services as determined in the review process. Applies APS authorization process (Milliman standards, policies, procedures, and contractual agreements) to submitted information. Authorizes services in accordance with medical and health guidelines. Coordinates with the referral source if there is not sufficient information available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows process for requesting additional information. Provides timely verbal/email/fax organization determinations to the requesting provider and/or members as per policy. Submits appropriate documentation/clinical information to clerical support for record keeping, mailing notifications and documentation requirements. Recognizes opportunities for referrals to Behavioral Health Case Management and refers accordingly. Identifies quality concerns through the review process and refers them to Quality Department for further investigation.Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS), NCQA, URAC and guidelines set forth by other regulatory agencies & HIPAA where applicable; obtains necessary professional and continuing education required for licensure and any applicable certifications. In addition, all other duties assigned by the manager and/or supervisor.Education:
Master’s Degree in a Behavioral Health field or bachelor’s degree in Nursing. Current, unrestricted clinical license(s) to practice in Puerto Rico territory.Experience:
Minimum 2 years of experience in a Clinical, Behavioral or Managed Care field preferred.Knowledge:
Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.Strong knowledge in behavior principles, chronic illnesses, and disease management. Strong telephonic assessment and customer service skills.Knowledge in community-based resources.Knowledge in clinical assessment and crisis intervention.Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum. Read LessPosition Summary:
The Health Professional 3/MCI its responsible for providing intensive follow-up to members exhibiting behavior or an environment that may predispose them to incompliance with medical treatment thus resulting in increased hospitalizations, costly treatments and/or worsening of their mental health status. Intensive follow-up may consist of telephonic follow-ups, home visits, integration and coordination care with community agencies and coordination depending on the necessity.
Essential Functions:
1. Conducts health risk assessment and identifies barriers that could affect or interfere with treatment effectiveness or adherence
2. Communicates with providers in the community regarding the consumer’s treatment needs and develops appropriate care plans for specialized needs of members
3. Follow-up by telephonic or/and community outreach and crisis intervention if necessary.
4. Provides chronic care management, empowerment, motivational interviewing, services coordination and other clinically based activities as assigned, based upon member’s severity of condition.
5. Educates the patient about their disease state as well as other health issues relating to their plan care.
6. Collaborates with other professionals to obtain better treatment results and overall care
7. Investigates, reviews and maintains data related to treatment, care and/or related services
8. Establish case discussions with Medical Consultant and/or Medical Director
9. Will represent the company in Court for cases under follow-up and prepare reports if necessary.
10. Documents all activities per APS policies and procedures.
11. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable.
12. And all other duties assigned by the manager and/or supervisor.
Education:
· Master’s Degree in Clinic Social Worker.
· Current, unrestricted license to practice preferred.
Experience:
· Minimum 2 years of experience in a Clinical, Behavioral or Managed Care field preferred.
Knowledge:
· Strong knowledge in behavior principles, chronic illnesses and disease management.
· Strong telephonic assessment and customer service skills.
· Knowledge in community based resources.
· Knowledge in clinical assessment and crisis intervention.
· Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
Read LessResumen del Puesto:
El Profesional de la Salud 3/MCI es responsable de proveer seguimiento intensivo a los miembros que presenten conductas o vivan en un ambiente que pueda predisponerlos a incumplir con su tratamiento médico, lo que podría resultar en hospitalizaciones frecuentes, tratamientos costosos y/o un deterioro en su condición de salud mental. El seguimiento intensivo puede incluir llamadas telefónicas, visitas al hogar, integración y coordinación de servicios con agencias comunitarias y otras gestiones según sea necesario.
Funciones Esenciales:
Realiza evaluaciones de riesgo en salud e identifica barreras que puedan afectar o interferir con la efectividad del tratamiento o la adherencia al mismo.
Se comunica con proveedores en la comunidad sobre las necesidades de tratamiento del consumidor y desarrolla planes de cuidado adecuados para las necesidades especializadas de los miembros.
Da seguimiento mediante llamadas telefónicas y/o alcance comunitario, e interviene en situaciones de crisis si es necesario.
Ofrece manejo de condiciones crónicas, empoderamiento, entrevistas motivacionales, coordinación de servicios y otras actividades clínicas asignadas, basadas en la severidad de la condición del miembro.
Educa al paciente sobre su condición de salud y otros aspectos relacionados con su plan de cuidado.
Colabora con otros profesionales para obtener mejores resultados de tratamiento y cuidado general.
Investiga, revisa y mantiene datos relacionados con el tratamiento, el cuidado y/o servicios asociados.
Establece discusiones de casos con el Consultor Médico y/o el Director Médico.
Representa a la compañía en el tribunal para casos bajo seguimiento y prepara informes cuando sea necesario.
Documenta todas las actividades según las políticas y procedimientos de APS.
Cumple con todas las guías establecidas por los Centros de Medicare y Medicaid (CMS) y otras agencias reguladoras aplicables.
Realiza todas las demás tareas asignadas por el gerente y/o supervisor.
Educación:
Maestría en Trabajo Social Clínico.
Licencia vigente y sin restricciones para ejercer (preferida).
Experiencia:
Mínimo de 2 años de experiencia en el campo clínico, conductual o de cuidado administrado (preferido).Conocimientos:
Sólidos conocimientos en principios de conducta, enfermedades crónicas y manejo de condiciones.
Fuertes destrezas de evaluación telefónica y servicio al cliente.
Conocimiento de recursos comunitarios.
Conocimiento en evaluación clínica e intervención en crisis.
Experiencia en el uso de computadoras, incluyendo Microsoft Word, Excel, PowerPoint y Outlook a nivel intermedio como mínimo.
Resumen del Puesto:
El Profesional de la Salud 3 realiza revisión de utilización y/o atención al cliente de manera telefónica; resolución de problemas, seguimiento y otros servicios relacionados para pacientes y miembros. Esta persona clave se enfoca en el compromiso del miembro, la educación y el empoderamiento, estableciendo recomendaciones que ayuden a manejar condiciones crónicas de salud y fomenten estilos de vida más saludables. Debe estar disponible mientras el personal no clínico realiza la evaluación inicial.
Funciones Esenciales:
Provee orientación y consulta en salud de manera telefónica y/o presencial para participantes y miembros, cumpliendo con las políticas y procedimientos de la compañía. Verifica y documenta la elegibilidad del miembro para los servicios. Investiga, revisa y mantiene datos relacionados con el tratamiento, el cuidado y/o servicios asociados, e identifica barreras que puedan afectar o interferir con la efectividad o adherencia al tratamiento.
Realiza triaje y evaluaciones urgentes de riesgo clínico, consultas clínicas especializadas, resolución de problemas a corto plazo, coordinación de servicios clínicos de emergencia o urgentes, referidos y/o seguimiento para miembros que solicitan servicios, según sea necesario.
Participa en determinaciones organizacionales para casos de Hospitalización Completa o Parcial, incluyendo pre-certificaciones y revisiones concurrentes, discutiendo preocupaciones de necesidad clínica/médica con el Asesor Médico interno cuando sea necesario. Colabora con otros profesionales para obtener mejores resultados de tratamiento y cuidado general. Se comunica e interactúa directamente con proveedores para facilitar y coordinar las actividades del proceso de Manejo de Utilización.
Verifica y ajusta los informes de Censo para todas las facilidades de Hospitalización Completa/Parcial, realiza revisiones concurrentes y retrospectivas cumpliendo con las políticas y procedimientos de la compañía. Colabora con las facilidades en la planificación de alta. Completa el resumen de alta utilizando la información clínica provista por las facilidades al cierre del caso. Genera números de autorización para propósitos de pago para todos los servicios de Hospitalización Completa o Parcial según determinado en el proceso de revisión.
Aplica el proceso de autorización de APS (estándares Milliman, políticas, procedimientos y acuerdos contractuales) a la información sometida. Autoriza servicios de acuerdo con las guías médicas y de salud.
Coordina con la fuente del referido cuando no haya suficiente información disponible para completar el proceso de autorización. Informa a la fuente del referido y solicita la información específica necesaria para completar el proceso. Documenta la solicitud y sigue el proceso para requerir información adicional.
Provee determinaciones organizacionales verbales/correo electrónico/fax de manera oportuna al proveedor solicitante y/o a los miembros según la política. Somete la documentación clínica correspondiente al personal administrativo para archivo, envío de notificaciones y requisitos de documentación.
Reconoce oportunidades de referido al Manejo de Casos de Salud Conductual y refiere según corresponda. Identifica preocupaciones de calidad durante el proceso de revisión y las refiere al Departamento de Calidad para investigación adicional.
Cumple con todas las guías establecidas por los Centros de Medicare y Medicaid (CMS), NCQA, URAC y otras agencias reguladoras aplicables, así como con HIPAA; obtiene la educación profesional y continua necesaria para la licencia y certificaciones aplicables.
Además, realiza todas las demás tareas asignadas por el gerente y/o supervisor.
Educación:
Maestría en Trabajo Social.
Licencia(s) clínica(s) vigente(s) y sin restricciones para ejercer en el territorio de Puerto Rico.
Experiencia:
Mínimo de 2 años de experiencia en el campo Clínico, Conductual o de Cuidado Administrado (preferido).Conocimientos:
Experiencia en computadoras, incluyendo Microsoft Word, Excel, PowerPoint y Outlook a un nivel intermedio como mínimo.
Sólidos conocimientos en principios de conducta, enfermedades crónicas y manejo de condiciones.
Fuertes destrezas de evaluación telefónica y servicio al cliente.
Conocimiento de recursos comunitarios.
Conocimiento en evaluación clínica e intervención en crisis.
Experiencia en computadoras a nivel intermedio como mínim
Read LessPosition Summary:
The Health Professional 3 conducts utilization review, and/or telephonic customer care; problem resolution, follow up and further related services for patients and members. This key individual focuses on member engagement, education, and empowerment, establishing recommendations that manage chronic health conditions and are conductive to healthier lifestyles. Must be available while non-clinical staff performs initial screening.
Essential Functions:
Provides telephonic and/or in person health coaching and consultation for participants and members, while meeting company policies and procedures. Verifies and documents member eligibility for services. Investigates, reviews, and maintains data related to treatment, care and/or related services and identifies barriers that could affect or interfere with treatment effectiveness or adherence. Performs triage and urgent clinical risk assessment, clinical expert consultation, short-term problem resolution, clinical emergency or urgent services coordination, referral and/or follow up for members seeking services, as needed. Participates in organization determinations for either Inpatient or Partial Hospitalization cases including pre-certification and concurrent reviews, while discussing clinical/medical necessity concerns within house Physician Advisor, as needed. Collaborates with other professionals to obtain better treatment results and overall care. Communicates and interacts via “live” encounters with providers to facilitate and coordinate the activities of the Utilization Management process. Verifies and adjusts Census reports for all Inpatient/Partial Hospitalization facilities, conducts concurrent and retrospective reviews while meeting company policies and procedures. Collaborates with facilities in the Discharge planning. Completes Discharge summary using the clinical information provided by facilities at case closure. Generates authorization numbers for payment purposes, for all Inpatient or Partial services as determined in the review process. Applies APS authorization process (Milliman standards, policies, procedures, and contractual agreements) to submitted information. Authorizes services in accordance with medical and health guidelines. Coordinates with the referral source if there is not sufficient information available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows process for requesting additional information. Provides timely verbal/email/fax organization determinations to the requesting provider and/or members as per policy. Submits appropriate documentation/clinical information to clerical support for record keeping, mailing notifications and documentation requirements. Recognizes opportunities for referrals to Behavioral Health Case Management and refers accordingly. Identifies quality concerns through the review process and refers them to Quality Department for further investigation.Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS), NCQA, URAC and guidelines set forth by other regulatory agencies & HIPAA where applicable; obtains necessary professional and continuing education required for licensure and any applicable certifications. In addition, all other duties assigned by the manager and/or supervisor.Education:
Master’s Degree in a Behavioral Health field or bachelor’s degree in Nursing. Current, unrestricted clinical license(s) to practice in Puerto Rico territory.Experience:
Minimum 2 years of experience in a Clinical, Behavioral or Managed Care field preferred.Knowledge:
Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.Strong knowledge in behavior principles, chronic illnesses, and disease management. Strong telephonic assessment and customer service skills.Knowledge in community-based resources.Knowledge in clinical assessment and crisis intervention.Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum. Read LessResumen del Puesto:
El Profesional de la Salud I ofrece servicio al cliente de manera telefónica y atiende oportunamente consultas relacionadas con el cuidado del paciente, elegibilidad, beneficios y reclamaciones, entre otros. Este rol también realiza seguimiento a los pacientes para asegurar la continuidad del cuidado y la eficiencia en la prestación de servicios. Este empleado no realiza actividades de Revisión de Utilización (UM) que requieran interpretación de información clínica.
Funciones Esenciales:
Verifica la elegibilidad del paciente y coordina citas cuando sea necesario.
Ofrece asistencia mediante comunicación verbal y escrita a suscriptores, familiares de pacientes, proveedores, representantes de cuentas y otros.
Autoriza el cuidado inicial del paciente conforme a las políticas y procedimientos de la empresa.
Realiza referidos no clínicos por teléfono, completa entradas de datos y documenta todas las llamadas de manera oportuna.
Lleva a cabo investigaciones para resolver consultas, reclamaciones y preguntas de los clientes.
Realiza llamadas de seguimiento para asegurar un cuidado efectivo y la prestación adecuada de servicios.
Mantiene comunicación activa con personal interno como Manejadores de Cuidado, Supervisores y otros gerentes departamentales.
El uso de datos clínicos se limita a:
Revisar solicitudes de servicio para verificar que estén completas
Recopilar y transferir datos no clínicos
Obtener datos clínicos estructurados
Actividades que no requieran evaluación o interpretación de información clínica
Cumple con todas las guías establecidas por los Centros de Servicios de Medicare y Medicaid (CMS) y otras agencias reguladoras aplicables.
Realiza cualquier otra función asignada por el gerente y/o supervisor.
Educación:
Bachillerato en Salud Conductual o campo relacionado (preferido).Experiencia:
Mínimo de 2 años de experiencia en servicio al cliente en un entorno de salud conductual o cuidado administrado (preferido).Conocimientos:
Capacidad para interpretar información de beneficios, cuentas y reclamaciones.
Dominio en entrada de datos.
Experiencia utilizando Microsoft Word, Excel, PowerPoint y Outlook a un nivel intermedio como mínimo.
Position Summary:
The Health Professional 1-Pharmacy Call Center Representative manages telephone calls from pharmacies and providers related to pharmacy benefits, authorization requests, drug use review, among others, to ensure that claims are correctly and timely adjudicated.
Essential Functions:
1. Answers and manages telephone calls from pharmacies and providers in a timely, confidential and courteous manner.
2. Documents calls and/or drug requests with complete follow-up history of the patient through electronic records.
3. Provides orientation to pharmacies regarding pharmacy benefits.
4. Performs system overrides (e.g., prior authorization) on the PBM claims processing system to ensure that claims are
correctly adjudicated.
5. Assists pharmacies claim processing.
6. Assist in the training of pharmacy representatives.
7. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable.
8. In addition, all other duties assigned by the manager and/or supervisor.
Education:
Pharmacy Technician Course of accredited school.Possess an active professional unrestricted Pharmacy Technician License in good standing to practice in Puerto RicoExperience:
· Minimum 2 years’ experience in retail pharmacy preferred.
Knowledge:
· Basic knowledge of physical and mental pharmacotherapies, in order to make accurate assessments of clinical cases.
· Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
Read LessPosition Summary:
The Business Analyst serves as liaison between business units and IT department to elicit, analyze, communicate, and validate requirements for changes to business processes, policies, and information systems. These key individual reviews, analyzes and evaluates business systems and user needs, including troubleshooting system integration issues, application and software issues and monitoring technology implementation initiatives in a regional area.
Essential Functions:
Provides connection between business owners and IT technical resources to initiate realistic solutions for contract requirements, workflows, and business needs.Participates in the design, development, and delivery of software applications training programs, coordinating closely with IT managers and non-technical business units to implement and define the support structure for business projects.Supports the Finance Manager in establishing joint, reusable, and shared strategic and tactical solutions. Collaborates with internal IT staff to coordinate delivery schedules and assure delivery of needed services and goods on time and within budget.Works closely with other departments to anticipate changes in functionality and priorities.Gathers and assesses strategic operational project status, issues, risks, and dependencies.Leads special projects in collaboration with interns. Complies with all guidelines established by the Centers for Medicare and Medicaid {CMS) and guidelines set forth by other regulatory agencies, where applicable. And all other duties assigned by the manager and/or supervisor.Education:
Bachelor's Degree in Information Technology, Business, Engineering, or related field .Experience:
Minimum 2 years of experience in project management and information systems; management of healthcare data preferred.Knowledge:
Knowledge and experience in Project Management.Personal computer experience should include working with Microsoft Word, Excel, Power Point, MS Visio, MS Project, and Outlook at the intermediate level at a minimum. SharePoint, SQL and other statistical software are desirable. Read LessResumen del puesto:
El Analista de Negocio sirve de enlace entre las unidades de negocio y el departamento de TI para obtener, analizar, comunicar y validar los requisitos para los cambios en los procesos de negocio, políticas y sistemas de información. Esta persona clave revisa, analiza y evalúa los sistemas empresariales y las necesidades de los usuarios, incluida la resolución de problemas de integración de sistemas, problemas de aplicaciones y software y la supervisión de iniciativas de implementación de tecnología en un área regional.
Funciones esenciales:
Proporciona conexión entre los propietarios de negocios y los recursos técnicos de TI para iniciar soluciones realistas para los requisitos contractuales, flujos de trabajo y necesidades empresariales.Participa en el diseño, desarrollo e impartición de programas de formación sobre aplicaciones informáticas, coordinándose estrechamente con los responsables de TI y las unidades empresariales no técnicas para implantar y definir la estructura de apoyo a los proyectos empresariales.Apoya al Director Financiero en el establecimiento de soluciones estratégicas y tácticas conjuntas, reutilizables y compartidas. Colabora con el personal interno de TI para coordinar los calendarios de entrega y garantizar la prestación de los servicios y bienes necesarios a tiempo y dentro del presupuesto.Trabaja en estrecha colaboración con otros departamentos para anticiparse a los cambios de funcionalidad y prioridades.Recopila y evalúa el estado, los problemas, los riesgos y las dependencias de los proyectos operativos estratégicos.Dirige proyectos especiales en colaboración con los becarios. Cumple todas las directrices establecidas por los Centros de Medicare y Medicaid {CMS) y las directrices establecidas por otros organismos reguladores, en su caso. Y todas las demás funciones asignadas por el gerente y/o el supervisor.Educación:
Bachillerato en Tecnología de la Información, Negocios, Ingeniería o campo relacionado .Experiencia:
Mínimo 2 años de experiencia en gestión de proyectos y sistemas de información; preferiblemente en gestión de datos sanitarios.Conocimientos:
Conocimientos y experiencia en gestión de proyectos.La experiencia en informática personal debe incluir el trabajo con Microsoft Word, Excel, Power Point, MS Visio, MS Project y Outlook a nivel intermedio como mínimo. Son deseables SharePoint, SQL y otros programas estadísticos. Read Less