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- 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...
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Administer and support Microsoft Configuration Manager (SCCM) and Microsoft Intune, including software deployment, operating system upgrades, device configuration, compliance management, and endpoint lifecycle administration
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- Leadership
- Selects, develops, mentors, and retains engaged and high-performing staff. Provides coaching, development opportunities, and performance management.
- Fosters a culture of accountability, collaboration, and continuous improvement.
- Manages relationships with vendors and...
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Pharmacy Specialist, Government Program Operations Role:
- Oversee the administration and implementation of pharmacy benefit programs, P&T Committee decisions, and benefit changes, including maintenance and updating of the formulary database, ensuring that medication lists are current and reflect the latest clinical guidelines and policy changes, and review/approval of testing by PBM and other vendors.
- Review pharmacy claims for accuracy, ensuring compliance with benefits policy guidelines and formulary requirements and...
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- Investigate other insurance information to coordinate benefits for claims processing
- Direct contact with members, CMS, or other health plans via telephone, letters, email, or portal submissions to obtain/verify other insurance information
- Determine primacy based on the other insurance obtained and confirm automatic filing order (AFO) is accurate
- Update Health Link with the other insurance information and ensure AFO is...
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- Financial Performance & Payment Integrity Oversight
- Oversees the financial and key performance indicators related to pre-pay integrity services, post-pay integrity services, premium revenue services, and remediation initiatives to ensure financial and key performance targets are met.
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