Job Listings

- Project Delivery and Quality - Supports efforts to ensure deliverables meet quality standards, compliance requirements, and customer expectations by participating in quality reviews, testing activities, and validation checkpoints. - Tracks project dependencies and risks and supports mitigation activities, including maintaining risk logs, assisting with contingency planning, and escalating blockers to maintain delivery continuity. - Follows established SDLC (Software Development Life...

- 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. -

- Deposits checks received for provider refunds, claims, and premiums for multiple entities using remote deposit capture - Maintains cash deposit logs, including, but not limited to, finance, claims, and recoveries - Scans documents for imaging - Completes Schedule A form 5500’s as requested by employer groups - Prints weekly pay cycle vendor checks -

- Review and apply regulatory coding guidelines to ensure accurate and compliant claims processing 

- Conduct medical necessity reviews and determinations of prior authorizations and referrals, including reviews of previously denied and appealed decisions - Oversight and day-to-day management of a team of Associate Medical Directors, and the Medical Policy Development team including performance management, timekeeping, and managing the MD calendar to ensure adequate coverage during business hours and ad hoc - Oversight of Medical Policy development - Provide clinical strategy and physician input to various Clinical Services...

- Perform server and system administration tasks, including group policies, print services and queue management, event log monitoring, security permissions, drive and volume management, OS provisioning, migrations, upgrades, and performance tuning. - Aid in the design, build, test, and deployment of new systems, services, and processes to meet ongoing business needs. - Perform routine maintenance including, updates, patching, backups, snapshots, configuration management, and disaster recovery. - Support internal and cloud infrastructure...

- Leverages knowledge and skill with a variety of query tools (Power BI, BusinessObjects, SAS, SQL, Python), analytic techniques, and platforms to analyze large quantities of data from multiple sources. - Designs, creates, and maintains dashboards, business plans, forecasts, projection models, etc. - Consults with business units, management, and vendors to analyze, develop and document detailed business requirements and business processes for proposed solutions to complex business initiatives. - Applies knowledge of healthcare industry...

- Proactively engage members identified as potentially eligible for alternative payer programs through phone, email, and other communication channels. - Provide clear, compliant education about eligibility, benefits, enrollment processes, and potential clinical advantages, following CMS, DHS, State of WI, and other regulatory guidelines. - Address member questions and concerns to support informed decision-making. - Assist members with application and enrollment processes as allowed under...

Risk Assessment & Pricing  - Quantify risks for level-funded products and calculate quotes and renewal rates using rating formulas, tools, and methodologies for prospective groups; validate accuracy of final rates and packaging. - Apply sound underwriting judgment and product pricing best practices to maintain a profitable book of business while ensuring compliance with company policies and...