The Manager of Clinical Appeals and Grievances leads a team to standardize and optimize appeal processes while ensuring compliance and high-quality case resolution. This role collaborates with organizational leaders to identify priority focus areas and manages internal and external production teams to meet performance targets.
The Principal Engineer drives cloud and operational excellence by managing enterprise solutions and automating system deployment and configuration. They act as a technical leader and mentor, establishing cloud standards and collaborating with development teams to ensure resilient service delivery.
The Sales Operations Service Agent provides high-quality support to brokers and agents by resolving inquiries regarding eligibility, benefits, claims, and commissions. They also collaborate with the management team to address service-related projects and improve operational processes.
The Outreach Retention Specialist is responsible for managing member outreach and retention efforts to support organizational goals. They will engage with members to ensure service continuity and address inquiries effectively.
The Clinical Specialist manages member complaints, grievances, and appeals by conducting clinical case development and resolution. They ensure compliance with federal and state regulations while managing caseloads and preparing cases for medical director review.
The Service Agent supports Contact Center Operations by addressing member and provider inquiries regarding eligibility, benefits, and claims. They are responsible for resolving complaints, maintaining HIPAA compliance, and ensuring an exceptional customer experience across all lines of business.
The Relationship Coordinator manages inbound and outbound calls to educate prospective members on long-term care services and Medicare Advantage plans. They are responsible for scheduling appointments, maintaining accurate records in Salesforce, and meeting established sales and productivity quotas.
The Care Coordinator manages an assigned member caseload to support health navigation and performs outreach to ensure services are in place. They also handle incoming calls regarding benefits and care coordination while documenting interactions in the PHI system.
The Information Owner aligns customer experience with enterprise information architecture and corporate strategy while overseeing data usage frameworks. They lead cross-functional teams in data integration, quality management, and the development of scalable data solutions.
The analyst leads end-to-end forecasting and capacity planning for multichannel contact center operations, ensuring strategic alignment and performance oversight. They translate demand forecasts into actionable staffing strategies while driving continuous improvement in models and methodologies.
The specialist is responsible for investigating and responding to clinical appeals and grievances from members and providers. This includes classifying cases, collaborating with other departments, and participating in regulatory site visits.
The Vendor Partner Specialist manages relationships with external vendors to ensure service level agreement adherence and quality auditing. They act as a liaison between department leaders and vendors to coordinate workflow, training, and process improvements.
The Service Agent supports Contact Center Operations by addressing member and provider inquiries and resolving complaints across various lines of business. They are responsible for maintaining high customer experience standards, preventing dis-enrollments, and ensuring HIPAA compliance.
The Medical Peer Reviewer consults on medical necessity within utilization management, ensuring adherence to internal and external regulations by assessing authorization requests and claims payments based on medical records. This role involves rendering determinations within regulatory timeframes, maintaining productivity standards, and collaborating across various medical and management departments.
