ProgenyHealth, LLC

Bilingual

• The Case Manager will focus on empowering the members’ family to support optimal wellness while advocating for the necessary medical services across the health care continuum.
• The Case Manager works in a telephonic managed care setting combining strong clinical knowledge and critical thinking to facilitate a plan of care that will ensure quality medical care for the high-risk member population serviced by ProgenyHealth based on the CMSA national standards for case management practice.
• Assesses the physical, functional, psychological, environmental, educational, and financial needs of members referred to the Case Management program.
• Completes needs assessments for all members in CM and develops care plans individualized to the needs of each member as per ProgenyHealth policies and procedures.
• Assigns risk stratification based on complexity of medical and social needs and determines ongoing frequency of calls to continually assess plan of care.
• Monitors the care plan to ensure effective, appropriate provision of services and adequacy of benefits.
• Interfaces with providers to assist with care coordination activities, which can include appointments, transportation, DME, etc.
• Provides education to members regarding condition, treatment plan, benefits, services, and how to access needed care.
• Monitors ongoing progress towards goal achievement and reassess changes in health status throughout continuum of care.
• Provides referrals to appropriate community resources; facilitates access and communication when multiple services are involved; monitors activities to ensure that services are actually being delivered and meeting the needs of the member.
• Participates in interdisciplinary and client rounds with pertinent health care team members to identify, clarify, and/or prevent risk, quality, or plan of care variances.

Nurse Case Manager – NICU, Bilingual in Spanish

• The Case Manager will focus on empowering the members’ family to support optimal wellness while advocating for the necessary medical services across the health care continuum.
• Works in a telephonic managed care setting combining strong clinical knowledge and critical thinking to facilitate a plan of care that will ensure quality medical care for the high-risk member population serviced by ProgenyHealth based on the CMSA national standards for case management practice.
• Assesses the physical, functional, psychological, environmental, educational, and financial needs of members referred to the Case Management program.
• Completes needs assessments for all members in CM and develops care plans individualized to the needs of each member as per ProgenyHealth policies and procedures.
• Assigns risk stratification based on complexity of medical and social needs and determines ongoing frequency of calls to continually assess plan of care.
• Monitors the care plan to ensure effective, appropriate provision of services and adequacy of benefits.
• Interfaces with providers to assist with care coordination activities, which can include appointments, transportation, DME, etc.
• Provides education to members regarding condition, treatment plan, benefits, services, and how to access needed care.
• Monitors ongoing progress towards goal achievement and reassess changes in health status throughout continuum of care.
• Provides referrals to appropriate community resources; facilitates access and communication when multiple services are involved; monitors activities to ensure that services are actually being delivered and meeting the needs of the member.
• Participates in interdisciplinary and client rounds with pertinent health care team members to identify, clarify, and/or prevent risk, quality, or plan of care variances.

Nurse Case Manager – NICU, Bilingual Spanish

Engineer

• Collaborate with engineering and product teams to design, develop, and support technical interoperability solutions
• Support interoperability initiatives throughout the planning, design, development, implementation, and production monitoring stages in a delegated authority healthcare environment
• Focus on Prior Authorization and Claims process improvements
• Maintain, update, and take ownership of existing and new interoperability products and integrations
• Participate in Agile Project Planning & Estimation meetings, reviewing feature backlogs and identifying potential impacts to timelines, budgets, resources, and project scope
• Facilitate clear communication and expectation alignment with integration partners
• Participate in client planning meetings discussing Electronic Data Interchange (EDI), Prior Authorization, Claims workflows, and Web Service interface designs with external partners
• Design, develop, implement, test, and support custom interoperability interfaces using NextGen Mirth Connect or equivalent integration platforms
• Write, optimize, and maintain SQL queries to support interface logic, data validation, and reconciliation
• Build and enhance integrations supporting Prior Authorization and Claims workflows
• Thoroughly analyze problem definitions, requirements, and software deliverables to ensure solutions are scalable, performant, and reliable
• Validate and verify that software and integration requirements are achieved
• Perform support duties for production data exchange solutions
• Monitor existing interfaces, resolving or escalating errors and performance issues as appropriate
• Troubleshoot complex Prior Authorization and Claims integration issues and perform root cause analysis
• Prioritize customer and operational issues appropriately and communicate updates clearly

Nurse Case Manager – NICU, Bilingual in Spanish

Nurse Case Manager – NICU, Bilingual Spanish

Interoperability Engineer