The Performance Integrity Analyst audits claims, enrollment, and customer service activities to ensure accuracy and adherence to mandated guidelines. They also provide performance reports, feedback, and recommendations for quality improvement to management.
The specialist provides clinical care management to assess, plan, and coordinate member healthcare needs while ensuring compliance with medical policies. They also collaborate with internal and external stakeholders to resolve issues and improve quality of care through evidence-based practices.
The Care Management Nurse provides clinical care management, including assessment, planning, and coordination to meet member healthcare needs. They collaborate with internal and external stakeholders to ensure compliance with medical policies and promote quality, cost-effective outcomes.
Provide administrative and technical assistance to sales staff and customers while focusing on customer education and retention. Manage inquiries, document actions in tracking systems, and explain benefits and eligibility procedures to stakeholders.
The Provider Electronic Data Specialist manages provider inquiries regarding EFT enrollments and processes transaction enrollments using the Availity portal. They are responsible for researching and resolving escalation issues while maintaining internal documentation and performing EFT testing.
The Clinical Inpatient Pharmacy Technician conducts post-service audits to ensure billing accuracy and analyzes billings for consistency with medical records and reimbursement policies. They also prioritize work to ensure timely record reviews and maintain compliance with federal, state, and accreditation regulations.
The Payables Accountant manages payment activities to suppliers, providers, and members, including auditing invoices and processing EFTs. They are also responsible for researching payment inquiries and ensuring financial policies and controls are maintained.
Supports the initiation, planning, execution, and closing of payment integrity projects in alignment with Enterprise Project Management Office standards. Coordinates project schedules, budgets, and documentation while facilitating meetings and reporting status to leadership.
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.
Risk Adjustment Auditors perform retrospective and prospective chart reviews to verify the accuracy and completeness of provider-reported diagnosis codes based on medical record documentation, ensuring accurate risk adjustment reporting. They also identify coding and documentation trends and collaborate with Provider Education Consultants to develop intervention strategies.
