This position supports pharmacy benefits by managing claims, prior authorizations, formulary exceptions, and appeals for members and providers. It also involves providing customer service, maintaining accurate documentation, and assisting with pharmacy-related projects.
This role provides leadership oversight for clinical decision tools and utilization management activities while managing multiple teams. It involves developing quality assurance processes, ensuring regulatory compliance, and collaborating across departments to meet organizational goals.
The IS Security Engineer II is responsible for designing, implementing, and maintaining corporate security systems to support business strategies. This role involves managing security technologies, analyzing business needs, and ensuring compliance with established security policies and standards.
The position is responsible for designing and developing complex data models, ETL specifications, and enterprise data architecture. It also involves leading system design, establishing data standards, and managing vendor relations to support organizational data needs.
The Actuarial Services Manager is responsible for managing actuarial components of financial reporting, including IBNR estimates, trend forecasting, and cost modeling. They also provide leadership to the actuarial team, ensuring alignment with organizational goals and effective cross-functional collaboration.
The Medical Director for Behavioral Health is responsible for implementing clinical strategies, utilization review, and care management initiatives to improve behavioral health delivery systems. They will also provide psychiatric consultation, oversee quality management programs, and collaborate with network providers to ensure high-performing care outcomes.
This position leads large-scale, complex projects and programs using project management and LEAN principles across the project lifecycle. The role acts as a liaison between internal and external stakeholders to facilitate collaboration, ensure accountability, and manage technical documentation.
The Medical Director oversees clinical and wellness programs, including utilization, case, and quality management initiatives to support member needs. They also serve as a medical spokesperson and provide leadership to clinical teams while ensuring compliance with regulatory and contractual requirements.
The Payment Integrity Analyst executes claims investigation and recovery strategies to identify cost containment opportunities and ensure payment accuracy. They collaborate with internal departments and external vendors to audit claims, document root causes of overpayments, and manage provider disputes.
