HealthCare Partners, MSO - Open Positions

Claims

Claims Audit Coordinator

The Claims Audit Coordinator is responsible for auditing claims processing activities to ensure compliance with HCP guidelines, specifically focusing on payment and procedural accuracy. This role plays a critical part in safeguarding the accuracy of completed claims before payment is issued, identifying trends, and recommending process improvements.

Coding

Medical Coding Analyst

The Coding Analyst will provide Risk Adjustment/HCC coding and auditing services that include the analysis and translation of medical and clinical diagnoses, procedures, injuries, or illnesses into designated alphanumerical codes. The Medical Coder will summarize audit results and provide feedback and education to the field team and providers regarding documentation needs and requirements.

Customer Engagement Center

Quality Outcomes Associate

The Quality Outcomes Associate (QOA) plays a key role in supporting high-impact Population Health programs through provider and member outreach, education, and engagement. This position is essential to driving continuous quality improvement in Healthcare Effectiveness Data and Information Set (HEDIS) measures, including Medicare Stars and Medicaid QARR.
As the external-facing quality liaison for HCP, the QOA ensures all communications align with HCP's corporate messaging and branding by working in close partnership with the Customer Engagement Center (CEC), Pharmacy, Risk Adjustment, Utilization Management, Quality, Network Relations, and other internal teams.

Core responsibilities include:
• Facilitating provider and member outreach to promote timely clinical interventions that improve health outcomes.
• Supporting medical record abstraction, retrieval, and data entry for HEDIS medical record review and supplemental data collection.
• Acting as a quality ambassador in external engagements, ensuring consistency in communication and alignment with strategic goals.

This role is instrumental in bridging internal quality initiatives with external provider and member engagement, ultimately contributing to improved performance metrics and member health outcomes.

Medical Management

Medical Director - UM Reviewer

The Medical Director will be responsible for assuring appropriate and optimized health care delivery for members. This position is primarily responsible for conducting medical necessity reviews, including prior authorizations, concurrent reviews, retrospective reviews, and appeals determinations. This role will focus on efforts to achieve excellence in healthcare cost management, quality, member experience, and improved population and member outcomes. They will serve as a clinical expert for teams dedicated to concurrent review, prior authorization, case management and strategic program development and implementation. The Medical Director will serve as a resource for our IPA physicians. The Medical Director will apply evidence-based guidelines to decision making, collaborate with other senior leaders in efforts that enhance the quality of care delivery, improve outcomes, and improve value delivered to our key stakeholders.

Nurse Case Manager, Prior Authorization RN

The Nurse Case Manager, Prior Authorization RN is responsible for reviewing and processing prior authorization requests for medical services, ensuring that all clinical criteria and health plan requirements are met. This role reports to the Manager of Inpatient Utilization Management and involves collaborating with healthcare providers, patients, and internal teams to determine the medical necessity of requested services, ensuring compliance with insurance guidelines, and maintaining accurate documentation. The Nurse Case Manager, Prior Authorization RN will support the goal of delivering timely and efficient authorization decisions while promoting quality patient care.

Nurse Case Manager, RN (Case Management)

The Nurse Case Manager is responsible for engaging members enrolled in case management to provide comprehensive care coordination and education aimed at improving health outcomes. This role involves assessing medical needs, developing individualized care plans, and collaborating with healthcare professionals to address barriers and ensure continuity of care. The Nurse Case Manager also monitors progress, adjusts care plans as necessary, and supports members in navigating the healthcare system to achieve optimal wellness.

Prior Authorization Review LPN

Position Summary: The Prior Authorization (PA) Nurse LPN is responsible for reviewing and processing requests for medical services that require approval from insurance providers. The LPN evaluates the medical necessity, appropriateness, and documentation for requested services to ensure compliance with clinical guidelines, payer requirements, and regulatory standards. The role supports efficient authorization processing and contributes to optimal patient access to care. Responsibilities include review of requests for service authorizations in order to monitor continuity and coordination of care and to assist in the utilization of appropriate services. Assists with complex cases and internal process development. Interacts with the Utilization Management Care Management and Pharmacy Teams to direct appropriate utilization and data capture.

Utilization Management Specialist

The Utilization Management Specialist plays a key role in optimizing healthcare resource utilization and ensuring adherence to quality and compliance standards. This specialist-level position involves expertise in reviewing healthcare service requests, including prior authorizations, inpatient services, denials, and appeals. The role implements utilization management strategies while collaborating closely with internal and external stakeholders to drive operational excellence and improve patient outcomes.

Network Relations

Provider Relations Specialist - Suffolk Country

HealthCare Partners (HCP) is dedicated to improving our healthcare ecosystem. The Provider Relations Specialist is the mission-critical linchpin between HealthCare Partners and our network of primary care physicians. This role focuses on fostering strong working relationships with PCPs and staff in an ongoing effort to advance HCP's organizational objectives, facilitate value based care, and improve both provider satisfaction and member health. The Provider Relations Specialist leverages data and knowledge of the primary care setting to identify PCP opportunities and tailor strategic action plans to support success. The Provider Relations Specialist serves as an internal subject matter expert with regard to their territory and collaborates cross departmentally to engage physicians optimally. This unique role blends a service and consultative approach to ensure HCP achieves its mission.