Careers
Assist Ambulatory Care Management Nurse with the day-to-day care management responsibilities; to provide efficient and effective ambulatory care.
Provide efficient and effective Ambulatory Care Management to members with high risk for hospitalization, re-admission and/or increased utilization of services by addressing the member's medical, physical and psycho social needs. Using clinical judgement develops, modifies and assists the member to implement their care plan.
Acts as liaison between NMM various departments such as UM, Claims, Eligibility and health plans by maintaining benefits in the system. Writes, maintain update and input Co-Pay and Benefits information into our system. Support other various projects as assigned by supervisor. Ability to audit claims to ensure Benefits are process correctly. Knowledgeable of the DOFR.
Assist Case Managers in assigned area of responsibility, including compiling information (open & close inpatient cases), fax authorization letters to providers, including sending denial letters and keeping records. Provide and coordinate information with outside agencies.
To implement the effectiveness and best practices of Case Management, the Case Manager will apply appropriate criteria for admission and continued stay in compliance with NCQA, CMS, and Health Plan delegation standards.
To implement the effectiveness and best practices of Utilization Management and provide UM functions and department support to comply with NCQA and Health Plan standards. Reports to the Director of Utilization Review.
Under general supervision, following established procedures, assist and direct patients in an empathetic and caring manner, efficiently and timely, and completes appropriate documentation. Responds to provider inquiries and attempts to resolve provider concerns or refers to management for resolution.
Process and adjudicates Professional CMS-1500 of encounter claims include pre-logged PCP and/or Pediatric claims.
Employee will provide coordination and assistance for multiple Data Management duties, including daily responsibilities and long-term projects. Provides support to NMM Data Management operations, including web portal management, incentive and risk adjustment programs, as well as other projects as required.
Pull EDI 837 files for claims audit
Mail forwarding claims
Edit EDI rejected log report
Process EDI 837 files using Bowman
Load EZ-Link files into EZ-Cap
Other duties & responsibilities as assigned by EDI supervisor
Organizes maintains and updates Ez-Cap eligibility information. Uses company proprietary software (Eligibility Manager and Datatug) applications to process membership. Makes sure members' eligibility is up-to-date in Ez-Cap from contracted Health Plans, checks health plan websites, and contacts Medi-Cal and Medicare offices. Handles checking eligibility, benefits, co-pays for authorization, and claims department. Keeps accurate logs of all the different projects of maintaining member eligibility. Working on conflicts and rejects related to members' eligibilities. In charge of in-loading membership in Ez-Cap for all IPA's. Calculate capitation and issue checks for all IPA's monthly. Maintain capitation accuracy monthly. Responsible for handling phone queues from providers and members related to eligibility and capitation questions. Create and run ad-hoc reports for membership, capitation, and other data information. Assists with calculating and reconciliation of capitation. Support other various projects as assigned by the manager.
Cleaners are responsible for maintaining the cleanliness of the building in which they work by performing various cleaning duties. Duties and hours may vary dependent upon the size of the building. A cleaner may be responsible for any or all of the following tasks. Tasks may also change throughout a cleaner's employment.
Writes health care management and decision support reports. Trains users on reporting tool and business applications. Administers SQL databases.
Medical Record Retrieval Specialist's job is to procure selective medical records from the care providers' central medical record repositories; such selective medical information may be utilized towards patient-specific needs, clinical verification and follow-up, collaborative clinical management, HEDIS supplemental information, and medical research. More significantly, medical records are retrieved at the request of coding, Quality Improvement, and Compliance staff which are essentially responsible for reviewing and verifying the accuracy of clinical data furnished for coding and other review and data abstraction activities. This position reports to the Senior Risk Adjustment Analyst.
Under general supervision, following established procedures, assisting and directing patients in an empathetic and caring manner, efficiently and timely, and completing appropriate documentation. Responds to provider inquiries and attempts to resolve provider concerns or refers to management for resolution.
The Provider Relations is to provide internal and external support to all IPA providers by providing guidance, training, education, direction, and support to the resolution of issues and/or concerns that would involve other departments. Responsible for handling and resolution of incoming provider inquiries, requests, and issues within IPA standards in a high-quality customer service and professional manner at all times.
This position will work closely on interconnecting internal and external data source for maintaining and auditing accurate provider database.
Set up non-contracted provider in EZCAP
Maintain existing contracted and non-contracted provider information in EZCAP
Assist in updating and maintaining Medi-Cal and Medicare Fee Schedule
Other duties may be assigned.
To implement the effectiveness and best practices of Utilization Management and provide UM functions and department support to comply with NCQA and Health Plan standards.