Case Management Coordinator - Field - OhioRISE Northeast/Northwest Ohio
CVS Health · Danville, VA
Job description(tap to read)
Case Management Coordinator We're building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. This is a full-time field-based telework position, in Ohio. This position requires the ability to travelwithin the assigned region of Northeast Ohio to member homes and other requested member locations, up to 50% or more of the time. Applicants may reside within the Northeast care coordination region of Ohio. Strongly prefers candidates to reside in one of the following counties: Marion, Crawford, Sandusky, Summit, Cuyahoga, Portage, Geauga, Lake, Ashtabula, Stark, or Belmont Monday-Friday 8-5pm with flexibility needed to work later to meet member needs. As part of the bold vision to deliver the "Next Generation" of managed care in Ohio Medicaid, OhioRISE will help struggling children and their families by focusing on the individual with strong coordination and partnership among MCOs, vendors, and ODM to support specialization in addressing critical needs. The OhioRISE Program is designed to provide comprehensive and highly coordinated behavioral health services for children with serious/complex behavioral health needs involved in, or at risk for involvement in, multiple child-serving systems. The Case Management Coordinator utilizes critical thinking and judgment to collaborate and inform the case management process, in order to facilitate appropriate healthcare outcomes for members by providing care coordination, support and education for members through the use of care management tools and resources. Must reside in Ohio. Fundamental Components: • Be clinically and culturally competent/responsive with training and experience necessary to manage complex cases in the community across child-serving systems. • Evaluation of Members: o Through the use of care management tools and information/data review, conducts comprehensive evaluation of referred member's needs/eligibility and recommends an approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services. Identifies high risk factors and service needs that may impact member outcomes and care planning components with appropriate referral to clinical case management or crisis intervention as appropriate. o Coordinates and implements assigned care plan activities and monitors care plan progress. • Enhancement of Medical Appropriateness and Quality of Care: o Using holistic approach consults with case managers, supervisors, Medical Directors and/or other health/behavioral health programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary review in order to achieve optimal outcomes. o Works collaboratively with the members' Child and Family Teams. o Identifies and escalates quality of care issues through established channels. o Utilizes negotiation skills to secure appropriate options and services necessary to meet the member's benefits and/or healthcare needs. o Utilizes influencing/ motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes to achieve optimum level of health. o Provides coaching, information, and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices. o Helps member actively and knowledgably participate with their provider in healthcare decision-making. o Serves a single point of contact for members and assist members to remediate immediate and acute gaps in care and access. • Monitoring, Evaluation and Documentation of Care: o Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures. Required Qualifications: • Bachelor's degree or non-licensed master level clinician required • 2+ years of experience in behavioral health, social services, or human services • 2+ years of experience with personal computers, keyboard and multi-system navigation, and MS Office Suite applications (Outlook, Word, Excel, SharePoint). • 2+ years of experience in children's mental health, child welfare, developmental disabilities, juvenile justice, or a public sector human services or behavioral health care field, providing community-based services to children and youth, and their family/caregivers. • 2+ year of experience with Ohio delivery systems, including local community networks and resources. • Willing and able to travel within the assigned region up to 50% of the time; Some travel to the New Albany office may be required for trainings/meetings: • Reliable transportation required • Mileage is reimbursed per our company expense reimbursement policy • Willing and able to work beyond core business hours of Monday-Friday, 8am-5pm, as needed. Preferred Qualifications: • Case management and discharge planning experience. • Managed Care experience. • Medicaid experience. Candidate will reside in Marion, Crawford, Sandusky, Summit, Cuyahoga, Portage, Geauga, Lake, Ashtabula, Stark, or Belmont County.Education Bachelor's degree or non-licensed master level clinician required, with either degree being in behavioral health, human services, health services, or public health preferred. (i.e. psychology, social work, marriage and family therapy, counseling, juvenile justice). Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $21.10 - $40.90 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments. We anticipate the application window for this opening will close on: 08/31/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
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Care Navigator Transitions of Care- CareBridge - 100% Virtual
Elevance Health · Danville, VA
Anticipated End Date: 2026-08-06 Position Title: Care Navigator Transitions of Care- CareBridge - 100% Virtual Job Description: Care Navigator Transitions of Care- CareBridge Virtual: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Build the Possibilities. Make an Extraordinary Impact. CareBridge Health is a proud member of the Elevance Health family of companies, within our Carelon business. CareBridge Health exists to enable individuals in home and community-based settings to maximize their health, independence, and quality of life through home-care and community based services. Work Hours: 5- 8hr shifts a week with 1 Saturday and 1 Sunday a month Eastern Time: 8:00AM - 5:00PM Central Time: 7:00AM - 4:00PM The Care Navigator Transitions of Care- CareBridge is responsible for ensuring that appropriate member treatment plans are followed on less complex cases and for proactively identifying ways to improve the health of our members and meet quality goals. How you will make an impact: • Coordinates follow-up care plan needs for members by scheduling appointments or enrolling members in programs. • Assesses member compliance with medical treatment plans via telephone or through on-site visits. • Identifies barriers to plan compliance and coordinates resolutions. • Identifies opportunities that impact quality goals and recommends process improvements. • Recommends treatment plan modifications and determines need for additional services, in conjunction with case management and provider. • Coordinates identification of and referral to local, state or federally funded programs. • Coaches members on ways to reduce health risks. • Prepares reports to document case and compliance updates. • Establishes and maintains relationships with agencies identified in appropriate contract. Minimum Qualifications: • Requires a H.S. diploma or equivalent and a minimum of 1 year related experience; or any combination of education and experience which would provide an equivalent background. • For Carelon - CareBridge business unit, bilingual or multi-language skills may be required. Preferred Skills, Capabilities and Experiences: • Certified nurse assistant or certified medical assistant and/or BS/BA degree in a related field preferred. • Bilingual candidates preferred. For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Job Level: Non-Management Non-Exempt Workshift: Job Family: MED > Care Coord & Care Mgmt (Non-Licensed) Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration. NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words - the job is posted until 3/13, not through 3/13.
Outpatient Facility Coding Compliance | , |
UnitedHealth Group · Danville, VA
Outpatient Coding Compliance Auditor Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data andresources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. The Outpatient Coding Compliance Auditor performs audits of outpatient facility (OPPS) coding to ensure accurate assignment of ICD-10-CM diagnoses, CPT/HCPCS codes, modifiers, and facility E/M levels (ACEP or client-specific). This role reviews coding for alignment with medical record documentation and established guidelines, ensuring compliance with applicable laws, regulations, and billing standards while effectively communicating findings to stakeholders. The Auditor also analyzes audit outcomes to identify trends, determine root causes, and pinpoint opportunities for improvement, as well as assess the effectiveness of corrective actions. Additionally, as part of the Compliance Workplan the Auditor participates in quality assurance (QA) coding oversight, conducts independent reviews, and supports organizational compliance initiatives. You'll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: • Perform coding compliance and quality audits in support of Optum Insight Provider's Compliance Program and client expectations • Independently analyze and interpret clinical documentation from medical records • Validate coding accuracy for outpatient facility, including E/M services, procedures, and modifiers • Identify audit findings, calculate billing error rates, and perform root cause analysis to determine drivers of non-compliance • Assess and evaluate the adequacy and effectiveness of corrective action plans, providing follow-up validation as appropriate • Clearly document audit findings and articulate results tailored to the appropriate audience • Prepare written audit analysis and summary reports, including compliance risk, trends, and recommended corrective actions • Conduct ad hoc coding and billing audits as requested • Provide compliance oversight of QA audit activities, ensuring consistency and adherence to established standards • Audit vendor coders and auditors, including offshore staff • Monitor and track evolving industry trends, regulatory updates, and government audit activities to identify potential coding and billing risk areas • Stay current with applicable coding, billing, and regulatory guidelines • Research, develop, and present targeted education based on individual, team, and systemic audit findings You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: • Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) or Certified Outpatient Coder (COC) • 5+ years of Outpatient Facility coding experience including: • NCCI/OCE billing edits related to outpatient services coding and billing • ICD-10-CM and CPT (including CPT-4) • ACEP Facility or similar Facility E/M matrix guidelines for outpatient facility code assignment • 5+ years of Outpatient Facility audit experience, including surgery, observation, and emergency department, including: (Strong industry knowledge of Medicare regulations and payment policies, including OPPS) Preferred Qualifications: • Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) or Certified Professional Medical Auditor (CPMA) a plus • Demonstrated ability to perform independent, autonomous audit and coding review functions • Strong professional communication skills, both oral and written • Ability to prioritize and manage multiple assignments, spreadsheets, documents, and reports • Proven time management skills with consistent follow-through to completion • Proficiency with Microsoft Excel, Teams, PowerPoint, Word, and Outlook Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 to $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.