Respond to and resolve, on the first call, customer service inquires and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility and claims, financial spending accounts and correspondence Help guide and educate customers about the fundamentals and benefits of consumer driven health care topics to select the best benefit plan o

Direct supervision of clinical staff within assigned areas to include remote locations Ensure compliance with Company policies, approved standards, and applicable laws and regulations; implement corrective actions as warranted Consistently model the organization's philosophy of customer service by demonstrating responsibility for improvement of operational efficiency Acti

Coordinates and handles outgoing nonstandard and more complicated eligibility files for ID cards, pharmacy vendors, 270/271 process, and other vendors Coordinates calls/meetings with external and internal customers (workgroups and multiple departments) including vendors Lead IT coding projects and tasks for the Enrollment System and Electronic Eligibility processes. Lead

Focus on initial and concurrent reviews for higher levels of care Make patient assessments and determine appropriate levels of care Care Advocates coordinate care with providers prior to discharge from inpatient, residential and partial hospitalization levels of care Manage inpatient mental health/substance abuse cases throughout the entire episode of care Administer bene

Assesses and interprets customer needs and requirements Identifies solutions to non standard requests and problems Solves moderately complex problems and/or conducts moderately complex analyses Works with minimal guidance; seeks guidance on only the most complex tasks Translates concepts into practice Provides explanations and information to others on difficult issues Coa

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; ensure compliance with local, state, and federal regulations Assess patients prior to initiation of home care service for appropriateness of services prescrib

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Manage overall delivery of benefits and services by providing support and guidance to existing and potential customers to ensure continued membership Provide expertise and customer service support to members, customers, and / or providers Identify and resolves operational problems using defined processes, expertise, and judgment Investigate claim and / or customer service

Assess, plan, and implement care strategies that are individualized by patient and directed toward the most appropriate, lease restrictive level of care Identify and initiate referrals for social service programs, including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact Co

Assess complaints of alleged misconduct received within the Company Investigate low to medium 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

Support primary team manager and director with all tasks related to appeal review Serve as a subject matter expert (SME) for benefit management and appeal cases review including job aids, processes, policies, regulations and clinical case review questions Assist with recruitment, onboarding, post training mentor for new hires and contract staff Lead meetings, presentation

Assess Medical Risk for the Company Review/Analyze Evidence of Insurability and determine appropriate course of action (e.g., request requirements, approve, rate, decline) Review/Analyze medical history of relevant populations (e.g., medical applications, APS, exams, claims history) to correctly and completely identify medical risk or potential increased risk of morbidity

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, at least restrictive level of care Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact

Responsible for conducting telephonic or face to face holistic evaluations of Member's individual dynamic needs and preferences gathering relevant data and obtaining further information from Member/family identification, evaluation, coordination, and management of member's needs, including physical health, behavioral health, social services, and long term services and sup

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, at least restrictive level of care Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact