The Manager, Claims Operations oversees the daily functions of the Claims Appeals, Medical Review, and Subrogation teams to ensure operational efficiency. They are responsible for leading staff, monitoring performance metrics, and implementing strategic initiatives to meet company goals.
The Specialty Rx Coordinator acts as a liaison between pharmacies and prescribers to manage pharmacy and medical prior authorization requests. They also oversee vendor relationships, negotiate single case agreements, and ensure compliance with governmental regulations.
The Account Manager oversees a portfolio of employer clients with self-funded medical plans, serving as the primary point of contact for brokers and employers. They are responsible for coordinating service issues, leading client meetings, and managing plan renewals and open-enrollment processes.
The Case Manager coordinates care plans for members by reviewing clinical documentation and claims to connect them with appropriate resources. They serve as a liaison between members, clients, and vendors while documenting case activity and evaluating health outcomes.
The Client Services Specialist acts as the primary point of contact for members, brokers, and HR representatives to resolve inquiries and benefit plan issues. They facilitate communication between clients and internal departments like Claims and Eligibility to ensure timely resolution and support account management strategies.
The Senior Refund Specialist reviews, analyzes, and determines solicited refunds based on claim guidelines and plan benefits. They also manage overpayment requests, track provider communications, and collaborate with internal teams to resolve complex billing cases.
The Manager of Claims Operations oversees the daily functions of the Claims Appeals, Medical Review, and Subrogation teams to ensure operational efficiency. They are responsible for monitoring performance metrics, implementing best practices, and providing leadership and coaching to staff members.
The Senior Data Scientist will design, develop, and evaluate production-grade machine learning models to support healthcare operations and business performance. They will partner with stakeholders to translate business questions into analytical approaches and provide actionable insights through dashboards and reporting.
The Senior Data Engineer will design, build, and maintain scalable data infrastructure, including pipelines and ETL/ELT processes, to support analytics and AI applications. They will also manage data storage patterns, ensure data quality, and collaborate with cross-functional teams to provide trusted reporting and machine learning datasets.
The Case Manager will evaluate clinical and claims information to develop and implement strategic care plans for members with various health scenarios. They act as a liaison between clients, vendors, and internal departments to optimize processes and ensure positive health outcomes.
Prepare, document, and submit aggregate stop loss claims, monitor their status, and follow up with carriers to secure timely and complete reimbursements. Reconcile and audit aggregate funding positions, respond to carrier information requests, and appeal denied or reduced reimbursements.
The Supervisor of Claims Processing leads daily operations, monitors team productivity and quality, and ensures claims are handled in compliance with regulatory requirements. They provide coaching and guidance to staff, resolve escalated issues, and support process improvements to enhance client and member experiences.
The IT Data Analyst will analyze and improve business processes while collaborating with department leaders to implement enhancements. They are also responsible for developing and maintaining KPI reports and supporting special time-sensitive projects.
The EDI Specialist is responsible for the daily retrieval, submission, and auditing of inbound and outbound data files. They also provide support to trading partners, conduct eligibility matching, and train staff on updated departmental procedures.
The GRC Analyst supports the development and maintenance of security controls while ensuring regulatory compliance across the organization. They are responsible for conducting risk assessments, managing vendor due diligence, and facilitating internal and external audits.
The Project Manager, Operations is responsible for managing the implementation of operational projects, new products, and services through the PMO delivery framework. They will collaborate with cross-functional teams to plan, execute, and deliver projects while ensuring alignment with governance and reporting standards.
The Supervisor, Stop Loss assists in overseeing department operations, including auditing claim filings, tracking reimbursements, and managing cash advance claims. They are also responsible for leading, coaching, and developing staff through performance appraisals and training initiatives.
The Client Service Representative acts as the primary point of contact for members, brokers, and HR representatives to resolve inquiries and issues. They liaise between clients and internal departments to manage claim resolutions, reporting, and the renewal of existing cases.
