The specialist collects, reviews, and manages medical records to support clinical reviews, quality programs, and regulatory audits. They coordinate with provider offices to resolve documentation gaps and ensure all records are audit-ready and compliant with privacy regulations.
Customer Service Representatives act as the primary contact for members to resolve inquiries regarding claims, enrollment, billing, and pharmacy benefits. They are responsible for providing exceptional service satisfaction and utilizing service recovery processes to assist members in complex situations.
The Broker Experience Representative serves as the primary point of contact for broker partners, providing support for enrollment, eligibility, and marketing inquiries. They collaborate with internal teams to resolve operational issues and maintain strong, positive relationships with partners.
The Credentialing Coordinator manages the end-to-end credentialing and recredentialing process for healthcare providers to ensure compliance with regulatory and accreditation standards. They also collaborate with cross-functional teams to maintain accurate provider data and support network integrity.
The Utilization Review Nurse is responsible for reviewing and documenting prior authorization requests and member case history to ensure compliance with coverage policies. They also analyze trends in case reviews to recommend revisions to medical and utilization management policies.
Perform high-level medical coding, audits, and analysis to ensure accurate claims processing and provider reimbursement. Serve as a subject matter expert for coding-related inquiries and maintain medical code sets within company systems.
Drive new business sales by managing strategic relationships with brokers and consultants for commercial large group business. Develop strategic sales plans and lead RFP responses to provide tailored healthcare solutions for clients.
