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Skills and experience required/desired: · Licensed Registered Nurse RN · 8+ years Medical or Case Management experience · 5+ years payer experience PCMH Resource Requirement: • Strong team-oriented professional with clinical expertise in a Payer environment. In depth understanding of the healthcare management industry, existing care management practices, program designs, and application/system implementations. • Understanding of broader care management models – primary care medical homes (PCMH) and accountable care organizations (ACO), and associated principles in cost of care management, patient experience improvement and better health outcomes. • Experience engineering best practices in areas such as use of health risk assessments and member health records, care and case management templates and designs, utilization management, disease management, authorizations/pre-authorization practices, etc. • Knowledge of health plan policies (e.g. what medical criteria should be applied to decide on approval or denial of authorization requests), regulations, operational impacts, and associated best practices. • Experience developing and implementing solutions in support of strategic business goals and direction. Skilled in assessing current practices and helping engineer improvements. • Ability to write clinical business rules to support care and case management policies, procedures and workflows. • Versed in project management, business analysis, requirements gathering, process and workflow modeling and translation to system design. • Strong communication skills, both internally and externally, in managing stakeholder expectations and enhance effectiveness of care management program Please send your updated resume to karan@ipsourceus.com Thanks and Regards, Prabakaran Louisraj (Karan) Director HR IPSource LLC., (732) 582 8341 karan@ipsourceus.com http://www.ipsourceus.com