
Medical Case Manager
2 semanas atrás
The Case Manager will work directly with the Senior Manager of Case Management to provide ongoing support and expertise through the comprehensive assessment, planning, implementation, and overall evaluation of those members who require medical care due to acute, chronic, or catastrophic events. The Case Manager will ensure that members receive appropriate care by proactively working with providers, estimating the future cost of care, and monitoring the members’ medical records. The overall goal of the position is to enhance the quality of patient management and satisfaction and to promote continuity of care and cost effectiveness through the functions of case management, utilization review and management, and discharge planning.ESSENTIAL JOB DUTIES AND RESPONSIBILITIESReview, monitor and proactively assess all cases with a focus on those cases with a high-cost potential (daily and ongoing).Assist and train Medical Coordinators to provide proper follow-up in high-cost cases.Ability to successfully prioritize and complete a multitude of different tasks.Acts as member advocate by investigating, documenting, reporting, and escalating adverse occurrences/situations to management.Prepares, coordinates, and facilitates a weekly Case Management Meeting.Acts as a key participant in the claim review meetings (i.E. Claims Review Committee and Big Claims Committee) and provides updates on high-cost cases.Manages care of members who require medical care for an acute, chronic, or catastrophic event using disease management parameters and quality criteria.Liaise and coordinate with medical professionals, administrators of healthcare providers, and members to ensure the cost-effectiveness and appropriateness of the treatment.Work and understand the scope of the pre-authorization and case assessment processes in compliance with the policy's terms and conditions.Maintain timely and thorough documentation of all interactions with healthcare professionals about member care to facilitate efficient claims processing.Developing and implementing individualized care plans and discharge planning for patients, considering their medical conditions, treatment goals, and resources available.Perform proper and detailed investigations of cases to ensure correct application of benefits.Maintain an updated case management report of high-cost cases.Work closely with the departments of Provider Services, Claims, and Patient Services.Work with the Precertification Medical Team and analyze if care received by our members was appropriate for the diagnosis and condition of the insured.Support the medical coordinator in reviewing medical records related to claims assigned by Claim Adjudicators through our document imaging application (Docuphase).Assist Precertification with the review of medical records for acute cases handled by the Medical Coordinators.Participate and support On-Call services.Perform other duties as designated by the Senior Manager of Case Management Dpt.DESIRED MINIMUM QUALIFICATIONSStrong knowledge of medical conditions and correlations between medical conditions and potential medical expenditures.Strong knowledge of managed care policies and principles.Ability to measure risk and potential impact of cases and claims for the business.Strong analytical abilities and attention to detail.Able to work independently with strong initiative and minimal supervision.Strong commitment to service, quality, and care of members.Ability to maintain a balanced workload and prioritize accordingly.Bilingual Portuguese – English (must be fluent in English) - speak, read and write.Spanish fluency could be a plus.EDUCATION AND EXPERIENCEMedical Physician with a minimum of 5 years of related healthcare experience.3+ years of experience in healthcare working in medical coordination, case management and/or medical audit.NECESSARY KNOWLEDGEFamiliar with health insurance principles and guidelines.Seniority levelAssociateEmployment typeContractJob functionAdministrative and Customer ServiceIndustriesInsurance#J-18808-Ljbffr
-
Medical Device Sales
Há 3 dias
São José do Rio Preto, Brasil Pentax Medical Tempo inteiroPosition:Medical Device Sales - Territory ManagerLocation:Boston, MAJob Id:20250807# of Openings:1About PENTAX MedicalOurmission is to improve the standard of patient care and quality of healthcare delivery by providing the best endoscopic products and services with a focus on QUALITY, CLINICALLY RELEVANT INNOVATION, and SIMPLICITY.Through leading edge R&D...
-
Complex Case Manager III
2 semanas atrás
São Paulo, Brasil Medica Tempo inteiroOverview Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for. We are a team that owns our work with accountability, makes data-driven...
-
Medical Device Sales
1 dia atrás
São José do Rio Preto, Brasil Pentax Medical Tempo inteiroPosition:Medical Device Sales - Territory Manager (OH)Location:Cleveland, OHJob Id:TMOH20250902# of Openings:1About PENTAX MedicalOurmission is to improve the standard of patient care and quality of healthcare delivery by providing the best endoscopic products and services with a focus on QUALITY, CLINICALLY RELEVANT INNOVATION, and SIMPLICITY.Through...
-
Medical Manager
4 semanas atrás
São José dos Campos, São Paulo, Brasil General Motors South America Tempo inteiroOverview On site - This position requires an employee to be on site on a full time basis. Role Brazil Medical Leaders is responsible for leadership and management of the Health Centers Processes within a country. Other responsibilities include personnel development, medical compliance and regulatory oversight, business integration, strategic review and...
-
Medical Device Sales
Há 3 dias
São José do Rio Preto, Brasil Pentax Medical Tempo inteiroPosition:Medical Device Sales - Territory Manager CalgaryLocation:Calgary, AlbertaJob Id:TM20250711# of Openings:1Company Overview:At PENTAX Medical we put our customers at the center of everything we do and strive to differentiate ourselves as a medical device company that delivers a remarkable customer experience.We accomplish this by ensuring that we...
-
Medical Manager
Há 5 dias
São José dos Campos, São Paulo, Brasil General Motors Tempo inteiro R$90.000 - R$120.000 por anoJob DescriptionOn site - This position requires an employee to be on site on a full time basisRoleBrazil Medical Leaders is responsible for leadership and management of the Health Centers Processes within a country. Other responsibilities include personnel development, medical compliance and regulatory oversight, business integration, strategic review and...
-
Medical Manager
Há 3 dias
São José dos Campos, São Paulo, Brasil General Motors South America Tempo inteiro R$120.000 - R$250.000 por anoJob DescriptionOn site- This position requires an employee to be on site on a full time basisRoleBrazil Medical Leaders is responsible for leadership and management of the Health Centers Processes within a country. Other responsibilities include personnel development, medical compliance and regulatory oversight, business integration, strategic review and...
-
Medical Manager
Há 3 dias
São José dos Campos, Brasil General Motors Tempo inteiroJob DescriptionOn site - This position requires an employee to be on site on a full time basisRoleBrazil Medical Leaders is responsible for leadership and management of the Health Centers Processes within a country.Other responsibilities include personnel development, medical compliance and regulatory oversight, business integration, strategic review and...
-
Sr Medical Manager
3 semanas atrás
São Paulo, São Paulo, Brasil Johnson & Johnson Tempo inteiro**Sr Medical Manager - Rheuma**At Johnson & Johnson, the largest healthcare company in the world, we come together for one purpose: to transform the history of health in humanity.Diversity & Inclusion are essential to continue building our history of pioneering and innovation, which has been impacting the health of more than 1 billion patients and consumers...
-
Sr Medical Manager
3 semanas atrás
São Paulo, São Paulo, Brasil Johnson & Johnson Tempo inteiro**Sr Medical Manager - Rheuma**At Johnson & Johnson, the largest healthcare company in the world, we come together for one purpose: to transform the history of health in humanity.Diversity & Inclusion are essential to continue building our history of pioneering and innovation, which has been impacting the health of more than 1 billion patients and consumers...