Conduct quarterly and ad hoc file audits to ensure compliance with regulatory standards such as NCQA, URAC, and CMS. Analyze audit outcomes, manage documentation in SharePoint, and provide process improvement recommendations to business unit directors.
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 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 clinical triage, risk assessment, and proactive outreach to ensure appropriate care access and facilitate transitions across the continuum of care.
The Managed Care Coordinator acts as a liaison between members, physicians, and operational teams to facilitate service requests and coordinate care. They are responsible for reviewing medical documentation, initiating member outreach, and assisting with case management tasks such as health assessments and appointment scheduling.
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 Appeals Resolution Analyst II manages medical appeal cases by assessing clinical needs against established standards and ensuring regulatory compliance. They also provide clinical liaison support, resolve high-priority inquiries, and coordinate with internal and external stakeholders to facilitate the appeals process.
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.
This role involves performing medical necessity reviews and processing appeals to ensure compliance with clinical guidelines and plan benefits. The analyst will also collaborate with claim policy teams and identify opportunities for medical policy development based on case outcomes.
The Pharmacy Specialist I is responsible for processing prior authorization requests and coordinating pharmacy services benefits. They also engage with healthcare providers and members to ensure formulary compliance and resolve claim issues.
The Appeals Resolution Analyst II-RN manages medical appeal cases by assessing clinical needs against established guidelines and ensuring compliance with regulatory standards. They also provide clinical liaison support, resolve high-priority inquiries, and facilitate the external review process.
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.
Facilitate and lead network provider negotiations for various medical lines of business, including hospitals, physicians, and ancillary providers. Collaborate with internal teams to implement contracts, manage provider files, and ensure compliance with regulatory and enterprise requirements.
The Pharmacy Specialist I is responsible for processing prior authorization requests and coordinating pharmacy services benefits while ensuring compliance with regulatory standards. They also manage telephonic interactions with members and providers to facilitate formulary compliance and resolve claim issues.
Lead the No Surprises Act (NSA) actuarial team by developing forecasts, reserves, and financial analyses. Partner with cross-functional teams to improve data collection and communicate financial risks and recommendations to senior leadership.
The role involves performing care coordination and implementing interventions for specialty populations to ensure high-quality, cost-effective care. Responsibilities include assessing clinical needs, partnering with healthcare teams, and monitoring member outcomes to facilitate transitions to independent status.
The role involves assessing patient clinical needs against guidelines to ensure appropriate levels of care and length of stay. It also requires coordinating high-quality, cost-effective care and managing transitions across the continuum of care.
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.
Responsible for designing and delivering provider education and performance management initiatives to improve patient experience, population health, and affordability. The role leads a team of clinical transformation specialists to drive value-based care goals and provider engagement.
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.
Lead complex process improvement initiatives to reduce costs and complexity across the enterprise using Lean Six Sigma methodologies. Act as a strategic consultant to business leadership, developing business cases and mentoring staff toward Green and Black Belt certifications.
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.
