Trainers research, develop, and deliver operational training while partnering with leaders to identify learning needs and evaluate participant performance. They also maintain operational content in knowledge management systems and provide mentorship to junior team members.
Prepare journal entries, account reconciliations, and reports supporting monthly and quarterly financial statements, analysis, and insurance regulatory reporting. Assist with asset reviews, financial examinations and audits, ad hoc analysis, process improvements, and the development of internal control policies and procedures.
The clinician performs essential case management activities including assessment, planning, and coordination to identify member needs and measure outcome effectiveness. They apply clinical expertise and evidence-based criteria to ensure compliance with medical policy while collaborating with physician advisors and internal departments.
The role involves managing accounts receivable processes, including handling past due or delinquent accounts and maintaining accurate financial records. The incumbent will communicate with internal and external stakeholders to ensure timely payments and support delinquency policy procedures.
Monitor vendor performance and project schedules, maintain project documentation, and prepare reports and presentations for management and project teams. Support risk adjustment campaigns by managing small projects and retrieving medical records through internal EMR access.
The Clinical Specialist researches and processes utilization management requests while ensuring compliance with regulatory and quality standards. They also conduct outreach to providers to manage medical records and communicate case determinations.
The nurse provides clinical care management, including case management and care coordination, to meet member healthcare needs and promote cost-effective outcomes. They collaborate with internal and external stakeholders to resolve issues, ensure compliance with medical policies, and maintain accurate documentation.
The Associate Medical Director applies medical expertise to ensure members receive quality, cost-effective clinical care through case management and peer-to-peer consultations. They also support the development of medical policies and clinical programs while collaborating with internal and external stakeholders.
The Treasury Specialist is responsible for daily bank activity monitoring, posting transactions, and performing account reconciliations. They also prepare journal entries and research payment discrepancies to ensure financial accuracy.
Performs comprehensive utilization management reviews to ensure adherence to medical necessity and policy standards. Collaborates with interdisciplinary teams to facilitate seamless transitions of care and provides accurate responses to internal and external inquiries.
The pharmacist will review medication effectiveness, safety, and cost to provide evidence-based guidance to members. They will work on a flexible, case-by-case basis to help patients make informed treatment decisions.
Pharmacists will review cases to provide evidence-based medication guidance regarding effectiveness, safety, and cost. They will also communicate with doctors or patients as needed to support informed health decisions.
The Appeals Clinician I applies clinical expertise to resolve member and provider appeals by ensuring decisions comply with medical policy and industry standards. They also consult with physician advisers and educate non-clinical staff on clinical cases to ensure appropriate determinations.
Act as a guide and advocate for members and providers by answering inquiries regarding health insurance benefits, claims, and eligibility. Conduct research to resolve complex issues and provide accurate, compliant information to callers.
