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- 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...
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Investigate, analyze, develop and implement Payment Integrity Policies
- Design, implement, and manage identity and access solutions to ensure secure and seamless authentication and authorization processes
- Maintain, optimize, and troubleshoot IAM tools and technologies, such as Okta, SailPoint, Microsoft Active Directory, or similar platforms
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- Manage multiple projects of varying complexities, including those with complex resource interdependencies.
- Serve as the primary owner throughout all project phases providing leadership, coordinating team efforts, and supporting decision-making to ensure projects are delivered on time, within scope, and within budget.
- Work with established guidelines and Enterprise Business Agility Coach to determine the most effective delivery approach.
- Work with the broader project management team to identify dependencies and interactions...
- Leads and manages the month-end and quarter-end close process, ensuring timeliness and accuracy of journal entries, reconciliations, and account analyses.
- Prepares and reviews financial statements in compliance with GAAP, ensuring accuracy, consistency, and completeness.
- Researches and applies GAAP to complex or unusual transactions including monitoring of new accounting standards and adoption efforts.
- Maintains and enhances internal controls over financial reporting,...
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...
- Collaborate with business users, external vendors and/or government entities to obtain data requirements for new analytics applications and data feeds or enhancement of existing products.
- Uncover appropriate sources of data for proposed application or data warehousing extension profiling data to ensure fitness for business purpose.
- Coordinate business requirements for the data and provide consultation to internal stakeholders to support their data needs.
- Understand source and target data structures, using standard data tools to...
