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Position Purpose: Supports community connection activities including connecting members to community resources to support their care management journey and provide necessary care resources in a cost-effective manner. Provides members with known community resources and supports the care team to ident

Position Purpose:Analyze and resolve verbal and written claims and authorization appeals from providers and pursue resolution of formal grievances from members. Key Details: Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorshi

Position Purpose: Identify training needs to enhance performance, quality, and motivation of corporate and field staff for the Quality department. Develop, conduct, and evaluate the effectiveness of training programs. Key Details: The Manager, Clinical Quality Training position is primarily remote.

Position Purpose: Develops, assesses, and facilitates complex care management activities for primarily physical needs members to provide high quality, cost-effective healthcare outcomes including personalized care plans and education for members and their families. Key Details: Position is remote. H

Position Purpose: Assist with the management of the financial affairs for all health plans. Key Details: Preferred candidates will be located in Missouri and able to work onsite approximately once per week (generally three times per month). A bachelor's degree in Accounting or Finance is required. I

Position Purpose: Supports care management activities and the teams assigned to members to ensure services are delivered by the healthcare providers and partners and continuity of care/member satisfaction is achieved. Interacts with members by performing member outreach telephonically or through hom

Position Purpose: Performs various duties specifically connected with protecting the employees, tenants, visitors, guests and property of the Corporation against threat or harm. Key Details: This is an onsite position based in Clayton, MO. Hours are Monday-Friday 6:30AM-2:30PM CST. Must be authorize

Abstractions and Overread experience highly preferred. MedSurge experience highly preferred. Position Purpose:Conduct review of delegated entities for compliance with quality, service performance and utilization, credentialing reviews and medical record audits. Perform community activities related t

Position Purpose: Develops, assesses, and facilitates complex care management activities for primarily physical needs members to provide high quality, cost-effective healthcare outcomes including personalized care plans and education for members and their families. Key Details: Applicants for this r

Position Purpose: Conduct fraud, waste, and abuse (FWA) investigations by reviewing referrals, claims data, medical records, provider information, and other relevant evidence to identify potential misconduct and support case resolution. Document investigative activities, prepare reports and referral

Position Purpose: Utilizes business expertise to facilitate, lead and drive complex large scale work efforts across domains and/or large scale cross functional initiatives with matrixed team support. Analyzes and measures the effectiveness of existing business processes and develop sustainable, scal

Position Purpose: Develops, assesses, and facilitates complex care management activities for primarily physical needs members to provide high quality, cost-effective healthcare outcomes including personalized care plans and education for members and their families. Key Details: This is a remote posi

Position Purpose: Maintain partnerships between the health plan and the contracted provider networks serving our communities. Build client relations to ensure delivery of the highest level of care to our members. Engage with providers to align on network performance opportunities and solutions, and

Position Purpose: Develops, assesses, and facilitates complex care management activities for primarily physical needs members to provide high quality, cost-effective healthcare outcomes including personalized care plans and education for members and their families. Key Details: This role requires up

Position Purpose:Serve as a liaison for external groups and providers regarding clinical information from the Operations and Medical Management teams. Assesses and performs review of member clinical records and services related to behavioral health and substance use. Key Details: This is a remote po

Position Purpose: Maintains relationships with physicians, hospitals, ancillary providers and Fidelis' internal Provider Network Management Dept. Acts as first line contact for providers/hospitals on claims projects and other non-routine claim issues. Oversees, in conjunction with the Adjustment and

Position Purpose: Coordinate and negotiate hospital, physician (IPAs, PPMs, individual providers, multi-specialty groups) and ancillary service agreements that are in accordance with corporate, health plan and State guidelines. Key Details: Must be authorized to work in the U.S. without the need for

Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate

Position Purpose: Supports community connection activities including connecting members to community resources to support their care management journey and provide necessary care resources in a cost-effective manner. Provides members with known community resources and supports the care team to ident

Note: This is a fully remote role with Central time (CST) working hours along with 10% travel. Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including empl