- Technical lead, with project management responsibilities to ensure projects are well-developed, tasks remain in scope and the project is completed on time.
- Demonstrates high level of understanding of the business requirements of the organization. Works with stakeholders to gain deeper understanding of requirements that are unclear.
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Maintain Network Infrastructure and Services
- Configure, administer, and monitor enterprise network systems (routing/switching, firewalls, VPNs, LAN/WAN, and Wi-Fi)
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Project Delivery and Quality
- Leads the planning, execution, monitoring, and successful delivery of complex technology and digital initiatives by developing work plans, roadmaps, milestones, and measurable outcomes.
- Oversees project...
- 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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- Develops project plans and leads initiatives that enhance the care management infrastructure.
- Monitors CMS, NCQA, and State regulations.
- Provide guidance to CM Leadership team on the system changes needed; ensure timely dissemination of information to staff.
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- 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,...
