Current Career Opportunities

Responsibilities:

• Perform the primary functions of case management–assessment, planning, facilitation, coordination, monitoring, evaluation, and advocacy–as appropriate in the health plan context to help members with high health complexity overcome biological, psychological, social and/or health system barriers to improvement and to achieve their desired clinical and functional outcomes.
• Conduct comprehensive assessments and develop personalized care plans in accordance with professional case management and accreditation standards, using evidence-based tools and applying relationship-building, motivational interviewing, risk-prioritization, and other related skills.
• Work collaboratively with members, families, and providers throughout the case management process, drawing upon knowledge of clinical, regulatory, and quality standards, health plan products and benefits, and community resources.
• Support members at all stages of their health care journey and across multiple settings and specialty areas, connecting with multiple providers and community-based organizations; guide members in accessing services to support their health and wellness goals in accordance with their benefits, partnering effectively with the Plan’s customer service, providers relations, and/or utilization management teams.
• Demonstrate a commitment to integrated, multi-disciplinary practice by proactively tapping into the expertise of the Plan’s clinical team of physicians, nurses, mental health clinicians, pharmacists, and colleagues in other departments who can help ensure the best possible experience and outcomes for the member.
• Participate in department and organization-wide initiatives to enhance member health and wellness, improve the quality of care, and generate cost-savings for our customers.

Qualifications:

• Graduate of an approved program in professional nursing: RN, VT licensure and ability to apply for Compact License or active multi-state licensure required, BSN desired;
• OR Licensed Clinical Social Worker (LICSW) in the State of Vermont or comparable degree and licensure in an allied mental health profession.
• 5 years of varied clinical practice experience required, preferably in a health care setting. Experience in the following clinical areas strongly desired: inpatient and post-discharge care, management of chronic conditions, including medical and mental health conditions, and substance use disorders.
• 1-3 years of case management or similar experience desired.
• Active CCM certification preferred or initiated within 2 years of hire. Completion of CCM certification required within 3 years of hire 

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Responsibilities:

• Execute utilization management processes to ensure the delivery of medically necessary and appropriate, cost effective and high-quality care through the performance of clinical reviews
• Reviews requests against standardized medical necessity and appropriateness criteria for an initial and a continued service authorization
• Identify questionable cases and refers to superior or a medical director for review

Qualifications:

• RN with Vermont License required; BSN desired.  
• 5 – 7 years of clinical practice required,
• 1- 3 years of insurance related experience desired.  
• Must be willing to participate in on-going CEU training.

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Responsibilities:

• Oversee maintenance of medical coding changes in our Payment Integrity programs
• Research requests using multiple systems (including: Sales Force, Jira, NPS) to provide all available details to reviewer
• Use SalesForce, Jira, and NASCO claim systems, to perform functions such as initial claim review, outcome reporting, and distribution based on triage
• Correspond with providers regarding decisions about requested services and obtain medical records when necessary
• Review and respond to issues and questions from internal and external customers, both verbally and in writing
• Work collaboratively with other departments to obtain additional information to resolve inquiries

Qualifications:

• Bachelor’s degree, or equivalent combination of education and experience, with a minimum of 3 years’ experience in medical coding; In-depth knowledge of CPT, ICD-9, ICD-10, HCPCS, DRG diagnosis and procedure coding
• Formal coding certification (eg: CPC, AAPC) is a must
• Experience with both professional and facility claims coding and in APC, HIPPS, or RUG coding and validation

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Responsibilities:

• Extract, transform, and load data and translate business requests/requirements into database design
• Work closely with internal and external parties to assist in the testing, implementation, and support of new initiatives
• Design, develop, and implement scalable On-Prem and Cloud solutions
• Utilize your skills in database technologies, data warehousing, and data architecture

Qualifications:

• BS/BA in an IT related discipline or equivalent work experience required. 
• 6-10 years of demonstrated software development experience preferably in a healthcare environment
• 6-10 years of experience with several of the following: T-SQL, SSIS, Azure Cloud, PowerShell, Web Services, TFS or other version control tools
• Excellent written and verbal communication skills 
• Proven analysis and critical thinking skills

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