The Personal Health Assistant supports members by coordinating care, navigating healthcare services, and providing referrals to community resources. They act as a liaison between members and service organizations while resolving billing, claims, and benefit-related issues.
The Director of Enterprise Applications is responsible for creating technology and digital strategy for a portfolio of up to 150 applications while leading a team of approximately 350 staff. They oversee the software development lifecycle, manage vendor relationships, and ensure high service levels for performance and availability.
Develop and implement comprehensive communication and education strategies to engage network providers and facilitate knowledge sharing. Manage educational projects, create informative content, and deliver training programs to ensure providers understand operational processes and quality standards.
Responsible for the accurate configuration and maintenance of provider reimbursement arrangements for healthcare professionals and institutions. Performs testing of price rules, fee schedules, and contract loads while resolving configuration issues identified by internal departments.
The analyst will resolve process inquiries from providers and compile reports on quality statistics to drive process improvements. They will also partner with facility staff to identify and resolve financial gaps, including open accounts receivables and claim payment issues.
The auditor is responsible for determining Medicare primacy, identifying overpayments, and processing Medicare demands in accordance with CMS regulations. They also manage system updates, review recovery opportunities, and respond to inquiries from various stakeholders.
The RN I assesses patient clinical needs against established guidelines to ensure appropriate levels of care and length of stay. They coordinate care across the continuum, monitoring outcomes and advocating for members while maintaining accurate documentation.
The role focuses on managing stop loss risk by identifying high-risk claimants and coordinating their care across the delivery system. It involves analyzing medical and pharmacy claims to ensure appropriate care levels and collaborating with internal and external stakeholders to optimize member outcomes.
The DSNP Care Manager is responsible for assessing the clinical, functional, and psychosocial needs of Dual Special Needs members to develop individualized care plans. They coordinate care across various settings, advocate for member resources, and monitor outcomes to ensure high-quality, cost-effective service delivery.
The clinician assesses patient behavioral health needs against established guidelines to ensure appropriate levels of care and length of stay. They coordinate care across the continuum, monitoring outcomes and advocating for members while maintaining accurate documentation.
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 serve as a physician subject matter expert for enterprise-wide strategic initiatives.
The Senior Professional Coder performs code abstraction and chart reviews to ensure compliance with ICD-10 and risk adjustment guidelines. They also analyze data results, educate staff, and conduct audits to improve provider performance and documentation quality.
The Pharmacy Specialist I is responsible for processing prior authorization requests and coordinating pharmacy services benefits for members. They also engage with healthcare providers to facilitate formulary compliance and ensure adherence to regulatory quality metrics.
This role is responsible for maintaining accurate provider data files and resolving data integrity issues within Government Programs systems. The analyst will also develop system enhancement specifications and produce departmental reports to ensure operational efficiency.
The analyst will assess vendor data to calculate financial penalties and support contract negotiations through cost analysis and budget forecasting. They will also validate invoice submissions and perform credit true-up analyses at the conclusion of projects.
This role involves assessing behavioral health clinical needs against established guidelines to ensure appropriate levels of care and length of stay. The clinician will coordinate care across the continuum, monitor outcomes, and advocate for members while maintaining accurate clinical documentation.
The Care Manager is responsible for assessing the clinical, functional, and psychosocial needs of Dual Special Needs members to develop individualized care plans. They coordinate services across the continuum of care and advocate for members to ensure access to necessary community resources and healthcare programs.
The analyst will develop and implement vulnerability scanning strategies to identify, assess, and remediate security risks across the enterprise technology environment. They will also collaborate with technology teams to prioritize remediation efforts and support threat intelligence and threat hunting initiatives.
This role provides medical leadership and guidance for utilization management activities within the behavioral health function. The incumbent supports clinician reviewers in making medical necessity decisions and analyzes data to identify trends in healthcare delivery.
The Inpatient Hospital Auditor II leads on-site and desk audits of hospital billing and coding practices to identify discrepancies and error trends. They also provide guidance to stakeholders on DRG assignment and payment regulations while coordinating the referral of improper claim payments.
The Operations Support Specialist II provides guidance and support to junior staff, manages audit inquiries, and assists in the development of training solutions. They also identify process trends, conduct performance observations, and collaborate with cross-functional teams to ensure quality and productivity goals are met.
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.
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.
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 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.
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 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.
