- Respond to customer inquiries related to their healthcare and/or health insurance primarily by phone, in a call center environment; may also use email, chat, written correspondence, web messaging, and in-person interactions, as needed
- Assess customer needs and provide appropriate support, including but not limited to: locating in-network providers, coordinating prior authorizations or referrals, analyzing claims to identify and resolve issues, supporting online portal navigation, health plan options, and setting appropriate expectations...
- Review and resolve a variety of claims-related items and reports—including more complex cases—using our claims processing system.
- Correspond with providers, members, and internal partners to gather information needed to adjudicate claims appropriately and timely
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Strategic Leadership & Program Oversight
- Partner with Care Management leadership to oversee initiatives that strengthen and enhance the Care Management programs, services, workflows, and outcomes
- Monitors and communicates regulatory and accreditation requirements, ensuring organizational readiness and compliance
- Consults with business units, management, vendors, and provider owners to analyze, develop, and document detailed business requirements and business processes for proposed solutions to business initiatives.
- Collects, manipulates, and analyzes data from multiple sources, draws accurate inferences, and presents findings to various levels of staff and collaborates on outcomes.
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- Develops and enforces security standards, procedures, and best practices to ensure alignment with the Information Security policy across the organization.
- Acts as a Subject Matter Expert in Information Security controls, advising on projects involving restricted and confidential data throughout the company.
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- Partners with the business to define and document processes and software requirements for technology initiatives.
- Serves as the primary liaison between business teams, development teams, vendors, and architects to ensure alignment from concept through delivery.
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- Technical lead, with project management responsibilities to ensure projects are well-developed, tasks remain in scope and the project is completed on time.
- Demonstrates high level of understanding of the business requirements of the organization. Works with stakeholders to gain deeper understanding of requirements that are unclear.
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- Program strategy and leadership
- Develops, implements, and leads the overall interoperability strategy, aligning it with the company’s broader goals and regulatory requirements.
- Leads cross-functional teams in executing interoperability projects and initiatives that drive operational efficiency and regulatory compliance.
- Defines and prioritizes project roadmaps, ensuring timely delivery of critical interoperability milestones and objectives across departments.
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