The role involves designing and implementing structured data quality approaches to ensure HEDIS data accurately reflects member health status. The analyst will lead quality performance analytics, translate business requirements into technical specifications, and provide actionable insights to improve clinical quality and cost efficiency.
This role provides rating and underwriting services for stop loss products, including developing proposal rates and experience-rated renewals for group sizes of 100+. The position also involves researching benefit inconsistencies, managing financial reports, and collaborating with sales teams and brokers.
This role focuses on stop loss risk management by identifying high-risk claimants and coordinating care delivery across the company. The incumbent will analyze medical and pharmacy claims to ensure appropriate care levels and support transitions for high-risk members.
Produce and analyze complex reports on network utilization, cost containment, and operational performance, using methods such as forecasting, modeling, regression, and data mining. Coordinate deliverables and project resources with customers, IT, vendors, and subject matter experts; present findings and recommendations, and mentor junior analysts.
Assess specialty-population members’ clinical needs, coordinate and advocate for appropriate care across providers and service settings, and implement interventions that support cost-effective care and transitions toward self-care. Monitor utilization and outcomes, document care, address complex cases with internal stakeholders, and contribute to quality improvement.
The Managed Care Coordinator acts as a liaison between members, providers, and clinical staff to facilitate service requests and coordinate care. They are responsible for reviewing medical documentation, initiating member outreach, and assisting with case management tasks under the supervision of clinical staff.
The CPC Investigator performs medical record audits and coding oversight to ensure compliance with coding guidelines and CMS standards. They also conduct investigations into suspected fraudulent activity, manage pended claims, and coordinate with law enforcement and other health plans.
Assess members’ clinical needs and the appropriateness of care, coordinate services and transitions across the continuum, and advocate for members while monitoring outcomes and resource use. Document care, collaborate with multidisciplinary teams, contribute to quality improvement and committees, and mentor staff as needed.
This role manages vendor strategy, performance measurement, and analytics for Enterprise Risk Adjustment programs. The incumbent will lead contract negotiations, oversee vendor relationships, and design KPI frameworks to ensure operational and financial success.
The Investigator II conducts analytical and investigative activities related to claims, enrollment, and accounting to detect and resolve suspected fraud. They are responsible for assembling evidence for potential prosecution, representing the company in legal proceedings, and managing fraud-related inquiries.
The role involves assessing patient clinical needs against established guidelines to ensure appropriate care and coordinating transitions across the continuum of care. Additionally, the RN will serve as a subject matter expert, mentor new staff, and advocate for members to ensure cost-effective and high-quality outcomes.
The Policy Support Specialist is responsible for reviewing medical policies, preparing cases for clinical review, and resolving clinical claims and service requests. They also coordinate appeal processes, manage pricing for clinical claims, and update coordination of benefit files.
The supervisor manages a Special Investigations Unit team focused on detecting fraudulent activities within the Federal Employee Program. They provide guidance on case management, represent the company in legal proceedings, and oversee staff development and performance.
This role involves coordinating patient care across the continuum, monitoring medical services for appropriateness, and advocating for members to ensure high-quality, cost-effective outcomes. The RN will also serve as a mentor to staff, participate in quality improvement programs, and act as a subject matter expert for medical management projects.
The Medical Director designs and implements provider education and performance management initiatives to improve population health and value-based care outcomes. They lead teams of clinical transformation specialists and collaborate with internal and external stakeholders to drive quality and affordability.
Develop government-program trend forecasts, pricing analyses, and experience studies, and evaluate the financial effects of benefit changes and state or federal regulations. Identify and support AI use cases across actuarial trend work, monitor adoption, collaborate with stakeholders, and communicate findings and recommendations to management.
Facilitate and lead network provider negotiations for various medical lines of business while collaborating with internal teams to ensure accurate contract implementation. Develop and maintain contracting policies, analyze medical cost savings, and ensure all agreements adhere to regulatory and enterprise requirements.
The incumbent manages end-to-end complaint and appeal cases by conducting thorough investigations and ensuring regulatory compliance. They coordinate with internal and external stakeholders to resolve issues and prepare comprehensive case files for leadership and legal review.
The Care Manager performs care coordination duties to ensure appropriate levels of care and plans transitions for specialty populations. They assess clinical needs, implement cost-effective care interventions, and partner with healthcare teams to meet member requirements.
The Care Manager is responsible for assessing the clinical needs of Dual Special Needs members and developing individualized, member-centric care plans. They coordinate care across the continuum, monitor medical outcomes, and advocate for members while ensuring services are medically appropriate and cost-effective.
The Underwriter Business Analyst supports new and renewal accounts by collecting data, setting up accounts, and producing quotes and policies. They also monitor underwriting funnel performance and assist underwriters with pricing data and report analysis.
The SNP Care Manager is responsible for assessing the clinical, functional, and psychosocial needs of Dual Special Needs members to develop individualized care plans. They also coordinate care across various settings and advocate for members to ensure access to necessary services and community resources.
The Appeals Analyst manages end-to-end complaint and appeal cases by conducting thorough investigations and ensuring regulatory compliance. They coordinate with internal and external stakeholders to deliver accurate resolutions and prepare comprehensive case files for leadership and legal review.
This role involves conducting on-site and desk audits of hospital billing and coding practices, including DRG validation and utilization review. The auditor will identify billing discrepancies, track error trends, and provide technical guidance to stakeholders regarding coding and payment regulations.
The RN I assesses patient clinical needs against established guidelines to ensure appropriate level of care and length of stay. They coordinate care across the continuum, monitor medical services, and advocate for members while maintaining accurate documentation.
The Actuarial Analyst II will support the No Surprises Act (NSA) team by managing data, developing forecasts, and performing financial impact assessments. They will also collaborate with cross-functional teams to improve data collection processes and communicate key financial results to senior leadership.
The resident will perform pharmacy case management, develop clinical policies, and conduct drug utilization reviews within a managed care environment. They will also assist with Pharm.D. student oversight and contribute to outcomes research and formulary development.
The Primary Nurse performs clinical assessments, develops member-centric care plans, and facilitates transitions across the continuum of care. They also monitor medical care activities, advocate for members, and serve as a mentor to new staff.
The specialist provides subject matter expertise to account management teams regarding underwriting, billing operations, and benefit design. They are responsible for maintaining strategic stakeholder relationships and supporting the growth and retention of the SHBP book of business.
The Actuarial Analyst II is responsible for pricing, underwriting support, reserving, and forecasting for Stop Loss and Level Funded groups. They will also design trend analyses and lead meetings with business partners to provide transparency regarding actuarial results.
The RN Case Manager is responsible for assessing patients' clinical needs and coordinating care to ensure appropriate levels of care. This role includes monitoring services, advocating for members, and collaborating with multidisciplinary teams.
