Provide primary care, including ordering and evaluating diagnostic/screening/laboratory tests, and management of minor acute illnesses Conduct comprehensive wellness assessments on members either in the clinic or patients' home as needed Assess diagnose and manage chronic conditions for patient population Identify deviations from normal, initiates and evaluates treatment

Reviews surgical and other professional claims for correct coding using clinical record Participation in Training regarding URAC, NCQA, Regulatory Compliance, Confidentiality, Conflict of Interest, HIPAA, and department specific training as applicable Participates in periodic clinical conferences / calls and in ongoing internal performance consistency reviews Composes, if

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

Accountable for customer (employer) loyalty and satisfaction, as measured by survey results and persistency Establish, cultivate, and manage the customer relationship at multiple levels, serving as a healthcare consultant and trusted business advisor to these customers Establish, cultivate, and manage relationships with consultants and brokers, recognizing the value they

Customer retention, based on established annual goals Strategic planning for multi year initiatives to identify opportunities to better manage healthcare trends Responsible for communicating and managing escalated issues and problem resolution as appropriate Maintains appropriate documentation including action plans, meeting notes, Strategic Customer Business Plans, Sales

Develop key internal and external relationships to facilitate results. Understand and create a strategy based on analysis and reporting of sales and market trends, including sales plan execution, competitive intelligence and new product requirements Drive the development of market sales strategies and value proposition formulation Lead as an expert in our national account

Perform initial and ongoing reviews pertaining to primary role (PA, ICM, DCM, PACM), appropriately applying clinical criteria (InterQual, policies, National and Local Coverage Determinations) for approval and sending to Medical Directors if review is necessary for determining an adverse determination Collaborate with Medical Directors, clinical peers and Health Plan partn

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Investigate medium to highly 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 information in the Special Investigations Unit's (SIU's) case t

Investigate medium to highly 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 information in the Special Investigations Unit's (SIU's) case t

Lead and manage implementation process for new and in force customers with a focus on supporting our National Account, larger Key Account and Leave Management business segments Drive and develop a customized implementation plan for each account; initiate and lead projects to identify and resolve implementation transition issues specific to each client Serve as point perso

Field inbound calls in a queue from members and providers for purpose of assessment and triage Focus on initial inpatient admission for psychiatric and chemical dependency patients Make patient assessments and determining appropriate levels of care Participate in member crisis calls Determine if additional clinical treatment sessions are needed Manage inpatient mental hea

Provide skilled nursing care for expectant mothers in the home care environment Travel to provide in home patient care and continuous education to patients and family members Continually assess the mothers' condition to ensure they are safe in the home environment Modify care plans as appropriate based on reassessment, change in prescriber orders, the patient's need for f

Provide consultation to providers and/or consumers on a variety of issues including benefit information, safety issues, confirmation of prior authorizations and approvals, procedures for higher levels of care evaluations, and request for an explanation of the level of care, coverage determination, or best practice guidelines Respect confidentiality and maintain confidence

Home health administrator responsibilities as assigned Special project management as assigned Additional responsibilities as assigned Primary Responsibilities Positively represent the Company to both internal and external customers; always maintain a professional and courteous manner Uphold the Optum core values in the conduct of work Adhere to Company privacy guidelines;