- Investigate and identify market industry trends.
- Perform data analytics to analyze the financial performance of our provider sponsors and risk panels.
- Research...
- 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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- Research official coding guidelines, industry sources, Quartz contracts, to evaluate and test system edits to support coding compliance and payment integrity
- Presents recommendations, including positive or negative financial savings to multi-disciplinary teams and leadership using analytics and industry research.
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- 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...
- Performs comprehensive whole-person assessments to evaluate member medical, behavioral, psychological and social determinants of health needs.
- Leads proactive member engagement initiatives designed to improve health outcomes, strengthen member relationships and support successful navigation of complex healthcare systems.
- Provides consultative education to members regarding health plan benefits, preventative care opportunities, healthcare options, and available community -based resources to support informed decision-making and...
- 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...
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Provide advanced, independent support for complex Legal and Compliance functions, including regulatory filings, corporate governance, contracting, vendor management, audits, and compliance...
- 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...
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...
