The representative will triage incoming calls from members, pharmacies, and providers to resolve claims-related issues while maintaining professional standards. They are responsible for documenting concerns, escalating complex cases, and ensuring high-quality customer care in a fast-paced environment.
The Customer Care Supervisor oversees daily call center operations, monitors performance metrics, and resolves complex customer inquiries. They are also responsible for training, mentoring, and supporting a team of remote agents to ensure high-quality service delivery.
The Supervisor oversees a team of pharmacists and technicians managing prior authorization and appeals processes across multiple lines of business. They are responsible for ensuring compliance, optimizing workflows, and performing clinical pharmacy functions including complex case reviews.
The supervisor will oversee a team of clinical pharmacists, managing prior authorizations, clinical programs, and provider outreach. They are also responsible for staff training, performance coaching, and collaborating on workflow and system enhancements.
The pharmacist trainer will develop and deliver training programs for pharmacy staff while ensuring clinical accuracy and regulatory compliance. Additionally, the role involves making clinical prior authorization and appeals determinations and providing backup support to the call center.
The Appeals Pharmacist is responsible for reviewing clinical coverage determinations and appeals for Commercial and Medicare lines of business. They will collaborate with Medical Directors and providers to facilitate appeal requests while ensuring quality and productivity standards are met.
Design, develop, and productionize machine learning solutions including document understanding, search, and generative AI applications. Collaborate with cross-functional teams to integrate AI models into backend services while ensuring data security and HIPAA compliance.
Design, develop, and productionize machine learning solutions including GenAI, NLP, and search applications. Collaborate with cross-functional teams to integrate AI models into backend services while ensuring system robustness and HIPAA compliance.
Develop and productionize multimodal LLMs and AI-based automation tools for healthcare applications such as document understanding and virtual agents. Manage the full ML lifecycle from data pipeline creation and model training to validation and deployment.
Review and make evidence-based decisions on prior authorizations, appeals, and override requests while ensuring regulatory compliance. Provide clinical support and guidance to members, prescribers, and pharmacies via phone.
The role involves preparing prior authorization requests by validating member information and obtaining necessary clinical data from providers. It also requires triaging calls and analyzing pharmacy claims data to ensure quality resolutions for members and stakeholders.
Prepare and validate prior authorization requests by obtaining necessary clinical information from providers and prescribers. Triage communications from members and pharmacies while ensuring adherence to HIPAA guidelines and internal procedures.
Responsible for processing first, second level, and external appeals for various lines of business including Commercial, Exchange, and Medicare. The role involves verifying case qualifications, coordinating with pharmacists and medical directors, and communicating with members and providers.
The developer will build and enhance a web-based enterprise health platform by implementing new features and improving existing functionality. This includes writing clean, maintainable code and collaborating with product managers and designers in an Agile environment.
The Senior AI/ML Applied Scientist will investigate and evaluate the latest LLM and MLM models for healthcare applications, develop data pipelines, and productionize machine learning solutions. They will also participate in the complete lifecycle of ML model development and ensure compliance with healthcare data regulations.
