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 Managed Care Coordinator acts as a liaison between members, providers, and clinical staff to coordinate care and verify benefits. They are responsible for performing initial screenings of service requests, managing case assignments, and translating clinical documentation between English and Spanish.
The Housing Specialist is responsible for identifying and securing community-based housing for Medicaid and MLTSS members while developing a broader housing strategy. They act as a central resource for staff, providing education on housing options and facilitating transitions to community settings.
The role involves conducting data collection and analysis to support process improvement initiatives aimed at reducing cost and complexity across the enterprise. The incumbent will lead projects, supervise business process analysts, and develop business cases using ROI models to improve productivity and efficiency.
The Sr. Analyst, Service leads end-to-end process analysis and transformation initiatives to improve operational performance and customer experience. They partner with cross-functional teams to design future-state processes, implement new technologies, and ensure operational readiness.
The analyst is responsible for driving financial reporting and analytical activities to evaluate P&L performance and support medical cost savings initiatives. They will also coordinate the Monthly Operating Review and provide data-driven insights for value-based program partners.
The Account Consultant delivers exceptional service to new and existing accounts to maximize satisfaction, retention, and growth. They partner with Sales and internal stakeholders to resolve complex issues and ensure successful account implementation and administration.
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 Care Manager assesses clinical needs and implements cost-effective care plans for specialty populations to ensure optimal health outcomes. They partner with members, families, and healthcare teams to coordinate resource utilization and facilitate transitions across the continuum of care.
The RN will perform clinical assessments for PCA and MDC services to ensure medically appropriate care and coordinate services across the continuum of care. They will also monitor patient outcomes, advocate for members, and assist with MLTSS case management as needed.
The Transplant Case Manager acts as a primary advocate and care coordinator, managing clinical caseloads and navigating complex medical, social, and financial barriers for patients. They perform telephonic triage, risk assessments, and coordinate care transitions while ensuring medical services are appropriate and cost-effective.
The analyst will assess vendor data to calculate financial penalties based on contractual performance and support contract negotiations through cost analysis and forecasting. They will also validate invoice submissions and perform credit or reimbursement true-up analyses at the conclusion of projects.
The RN Care Manager assesses patient clinical needs against established guidelines to ensure appropriate care and coordinates the transition across the continuum of care. They also serve as a subject matter expert, mentor new staff, and advocate for members to ensure cost-effective and high-quality outcomes.
The RN performs clinical assessments to ensure medically appropriate care and develops individualized care plans for high-risk members. They also coordinate care across the continuum, facilitate transitions, and serve as a mentor to new staff members.
This role involves assessing patient clinical needs against established guidelines to ensure appropriate levels of care and length of stay. The RN will coordinate care plans, monitor medical services, and advocate for members across the continuum of care.
Facilitate and lead complex network provider negotiations across multiple medical lines of business to ensure alignment with strategic and financial objectives. Collaborate with internal teams to manage contract implementation, resolve operational deficiencies, and ensure compliance with regulatory and accreditation standards.
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 II coordinates and monitors patient care across the continuum, ensuring high-quality and cost-effective outcomes through clinical practice guidelines. They also serve as a mentor to staff, act as a subject matter expert for projects, and advocate for members throughout their healthcare journey.
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 entire continuum, monitoring outcomes and advocating for members to ensure high-quality, cost-effective service delivery.
The analyst is responsible for performing internal and external vulnerability assessments, managing scanning programs, and evaluating security exceptions. They will also partner with technology teams to prioritize remediation efforts and support threat hunting initiatives to reduce organizational risk.
The Care Manager assesses the clinical needs of Dual Special Needs members and develops individualized, member-centric care plans. They coordinate care across the continuum, monitoring medical activities and outcomes to ensure services are medically appropriate and cost-effective.
Manage the resolution of out-of-network billing disputes and negotiate reimbursement for inadvertent or involuntary services. Ensure all cases are handled within regulatory timeframes and perform root cause analysis to prevent future escalated complaints.
Resolve complex customer inquiries and escalated issues through investigation and documentation. Coach junior staff and serve as a liaison between internal and external operational contacts to ensure high service levels.
The role supports premium rate development and pricing strategies for the Large Group market through financial impact studies and predictive modeling. It also ensures regulatory compliance, including Mental Health Parity reviews and state/federal rate filings.
Perform actuarial and data analytics for risk-adjusted business lines including ACA, Medicare Advantage, and Medicaid. Develop insights to guide risk adjustment strategy, financial projections, and pricing efforts.
The role focuses on the conservation of existing public market accounts and selling additional product lines to maximize retention. Responsibilities include negotiating contract terms, conducting client workshops, and ensuring stakeholders are informed of regulatory issues.
Lead a growth operations team focused on pipeline management, BANT qualification, and CRM hygiene to scale the enterprise growth engine. Coordinate executive-level meeting generation and orchestrate complex enterprise deals across cross-functional teams.
Supports the Quality Management department through project planning, implementation, and the establishment of policies for Government and Commercial programs. Analyzes complex data to improve health plan quality ratings and member experience through CAHPS coaching and provider action plans.
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.
