utilization review

Regular Exempt **GENERAL DESCRIPTION:** Evaluates utilization in clinical records and hospital facilities concurrently and retrospectively. Identifies and refers to other clinical departments (Case management, condition management, among others) cases for the management of treatment alternatives. Makes efforts to receive advice in difficult...

**Purpose Statement** Proactively monitor utilization of services for patients to optimize reimbursement for the facility. **Essential Functions** - Act as liaison between managed care organizations and the facility professional clinical staff. - Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care...

Regular Non-Exempt **GENERAL DESCRIPTION:** Responsible for handling, validating, and completing requests and reconciliations related to the Beneficiary Value Program. Assess program reconciliation and collaboration with cross-functional teams to enhance overall program performance to ensure that the Beneficiary Value Program goals align with the...

Regular Exempt **GENERAL DESCRIPTION:** The Events and Promotions Executive is responsible for handling and coordinating the logistics of Classicare events and activities and the efforts and initiatives related to the Advantage line of business. Identifies and develops work plans for region-level initiatives and provides recommendations to...

**Description** The Assistant Department Manager is responsible for the managerial direction and leadership of interns, designers and assistant-level engineers within the Substation Department of the T&D Global Practice in the Puerto Rico office. This position involves leadership and technical execution with direct involvement in projects. Specific...

## Overview PURPOSE STATEMENT: Manage the client's/patient's/resident’s cases with a solid background of clinical knowledge and expertise and may be responsible for providing some therapeutic services to clients/patients/residents. ## Responsibilities ESSENTIAL FUNCTIONS: · Provide case management and care coordination services for...

**Purpose Statement** Manage the client's/patient's/resident’s cases with a solid background of clinical knowledge and expertise and may be responsible for providing some therapeutic services to clients/patients/residents. **Essential Functions** - Provide case management and care coordination services for clients/patients/residents in the...

Regular Non-Exempt **GENERAL DESCRIPTION:** Analyzes claims and/or adjustments submitted in Centers for Medicare and Medicaid Services Form 1500 (CMS‑1500) and Uniform Billing Form 04 (UB‑04) formats, as well as member reimbursements, by applying payment rules to determine appropriate adjudication, denial, or the need for additional...

Regular Exempt **GENERAL DESCRIPTION:** Responsible for identifying, analyzing, and implementing impactful health services network management initiatives focused on enhancing service quality, driving process improvements, and ensuring contractual compliance. Translates strategic plans into actionable initiatives, effectively operationalizing them...

About OncoHealthOncoHealth is a leading digital health company dedicated to helping health plans, employers, providers, and patients navigate the physical, mental, and financial complexities of cancer through technology enabled services. Supporting more than 14 million people in the US and Puerto Rico, OncoHealth offers digital solutions for treatment...

Service Project Supervisor Manage controls, mechanical, and electrical projects consisting in major repairs, design and build, or new installations. Leads the service team to produce services required to keep buildings in shape and under budget, exceeding customer expectations consistently. Job Description & Responsibilities Plan, manage...

Duties The incumbent serves as a member of the HR Liaison team and is responsible for providing advice and assistance in the following areas: Staffing/Recruitment, Employee Development, Employee Benefits/Relations, Labor Relations, Awards and Recognition, and administrative functions related to these areas. Duties Include, But Are Not...