- Investigate and identify market industry trends.
- Perform data analytics to analyze the financial performance of our provider sponsors and risk panels.
- Research...
- Provides appropriate notification to nursing staff of all requests and hospitalizations requiring further review
- Makes approval determinations according to written protocols and guidelines as appropriate. Refers any medical questions or potential denial determinations to nursing staff for further review.
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- Research and validate business decisions and system rationales to support edits and conduct testing to validate outcomes. Provide education as appropriate to providers and leadership.
- Analyze billing and coding patterns and identify outliers with potentially high-risk practices.
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- Perform clinical reviews of prior authorization requests.
- Conduct prospective, concurrent, and retrospective medical review of members requiring inpatient, SNF and home health services.
- Coordination of care and treatment plans, and transition of...
- Design and perform complex operational and compliance audits across multiple business areas, identifying errors and process gaps that may not be detected by operational teams.
- Analyze audit findings to identify trends, perform root cause analysis, and develop recommendations that reduce risk and improve quality.
- Develop comprehensive audit plans by researching business operations, regulatory requirements, and insurance industry guidance.
- Ensure compliance with federal, state,...
- Manage the quote process for all assigned new business accounts from RFP (Request for Proposal) through close of sale. Partner with team to build value-based solutions, creates and presents compelling sales strategies to meet broker and prospect needs and executes follow-through to win new business accounts to attain sales goals.
- Proactively initiate...
- Evaluate and assess provider network contracts for new and existing provider agreements, ensuring mutually beneficial terms that are aligned with current national and local competitive landscape and practices
- Identify outliers and opportunities for improvement in new and existing provider agreements
- Perform financial analysis, fee schedule generation, and analytics in accordance with internal...
- Conduct thorough assessments to determine member health objectives and obstacles to care.
- Develop and implement individualized care plans in collaboration with the care team.
- Act as a strong advocate, valuable resource, and dedicated educator for members and their families.
- Leverage chronic disease management concepts, including health screenings and other preventive health activities to support...
