The Director of Customer Care Operations is responsible for overseeing operational performance, service quality, and continuous improvement across a large team of pharmacy technicians and customer service agents. This role involves setting strategic direction, managing budgets, and partnering with cross-functional teams to ensure compliance and high-quality service delivery.
The representative will triage incoming calls from members and pharmacies while resolving issues and documenting concerns. They will also support the Fraud, Waste, and Abuse program by reviewing pharmacy claims and ensuring adherence to company policies.
The Quality Assurance Manager will lead and scale the QA strategy, overseeing test automation, process optimization, and cross-functional collaboration. They will mentor a team of QA engineers while ensuring consistent quality standards and alignment with business goals across the software development lifecycle.
The Clinical Programs Administration Specialist supports clinical operations by triaging calls and conducting outreach to members, prescribers, and pharmacies. They are also responsible for documenting case activities and ensuring compliance with regulatory requirements and internal SOPs.
The Medical Director performs medication utilization reviews, medical necessity appeals, and clinical determinations for various health programs. They also provide peer-to-peer support to prescribers and contribute to the development of clinical policies and utilization management criteria.
The VP of Insured Products will oversee business development and manage the company's strategy for insured product offerings, including stop loss and captive management. They will also lead, mentor, and train sales executives while collaborating on product development and operational efficiency.
The Utilization Management Pharmacist reviews prior authorization requests and appeals to ensure safe and effective medication use. They also provide clinical support to members and providers while maintaining compliance with regulatory standards.
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 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.
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.
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.
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 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.
