The Data Analyst Lead acts as an internal consultant to develop complex healthcare, clinical, and financial data sets for reporting and decision support. They are responsible for mining data, identifying cost and utilization patterns, and training team members on analytical tools and processes.
This role manages the day-to-day operations of the credentialing function, ensuring compliance with health plan and NCQA requirements. It also involves providing leadership to the credentialing team and overseeing delegated credentialing processes for affiliated entities.
The analyst is responsible for maintaining and validating provider data to ensure accuracy across internal systems, payer platforms, and regulatory submissions. They will also manage credentialing data, create health plan provider rosters, and develop analytical reports to monitor performance.
The Utilization Management Nurse will perform prospective and retrospective utilization reviews to determine medical necessity for hospital admissions and outpatient services. They will collaborate with healthcare providers, health plans, and internal teams to ensure accurate authorization processes and adherence to clinical guidelines.
The Medical Director oversees utilization management policies and procedures to ensure high-quality, efficient healthcare delivery across the network. This role facilitates clinical rounds, manages physician education on utilization goals, and acts as a liaison for health plan appeals and clinical reviews.
Perform prospective and retrospective utilization reviews for hospital admissions and outpatient services to determine medical necessity. Coordinate with health plans, providers, and medical directors to manage authorization requests and ensure accurate case data entry.
Manage incoming authorizations via Tapestry Link and OnBase while ensuring compliance with ICE regulations and turnaround times. Act as the primary contact for internal and external customers regarding authorization requests and clinical documentation.
The Health Navigator supports clinical staff by coordinating care and assisting members in accessing medical, social, and behavioral services. Responsibilities include documenting care gaps, facilitating communication between patients and providers, and providing guidance through the healthcare continuum.
The Accounting Manager oversees the financial accounting process, including general ledger maintenance, monthly closes, and financial reporting for all AHS entities. They are also responsible for establishing internal controls to prevent fraud and assisting the Controller with the annual budget process.
The Pharmacy Technician supports the Clinical Pharmacy Team in implementing medication management programs and improving Pharmacy Quality programs. Key duties include conducting member calls to address gaps in care and documenting clinical activities in electronic health records.
The Senior Actuarial Analyst will generate and distribute reports to support risk adjustment calculations and financial reporting, while also conducting complex revenue analysis. This role involves collaborating with various departments to provide business intelligence and analytics.
