The Claims Operations Manager oversees Medicare claims production, vendor management, and ensures operational compliance with CMS regulations. They are responsible for developing internal controls, managing staff performance, and coordinating with cross-functional teams to resolve claims-related issues.
The Sr. Network Manager is responsible for developing, executing, and maintaining provider network strategies while managing contracting and network development across all lines of business. They will negotiate with various healthcare providers, analyze network gaps, and ensure cost-effective functionality through ongoing relationship management.
The specialist will manage the intake, tracking, and resolution of supplemental benefit vendor escalations to ensure timely member support. They will also analyze operational trends and coordinate across internal departments to improve vendor performance and member experience.
The Pharmacy Quality Assurance Analyst ensures pharmacy operations align with CMS and NCQA regulatory standards through internal audits and process improvements. This role involves analyzing claims data, managing corrective action plans, and supporting system enhancements to maintain compliance.
