- Drive sustainable membership growth, revenue performance, and enterprise value creation across all lines of business.
- Define and execute an enterprise-wide growth strategy supporting expansion, retention, and profitability objectives.
- Leverage market expertise, intelligence, analytics and customer insights to guide strategic product portfolio decisions including the product innovation roadmap, new product development and design initiatives, go-to-market strategies, and overall product lifecycle management.
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- 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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- 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...
- Perform collection activities for outstanding premium balances across employer groups, Health Insurance Marketplace members, and individual accounts.
- Send late payment notices and monitor accounts throughout the delinquency and grace period process.
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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,...
- 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...
