Elevance Health

Community Manager

• Engage with members to remove barriers to Social Determinants of Health (SDOH)
• Work with members to establish goals for addressing SDOH
• Support members in selecting appropriate provider/programs
• Act as liaison between referral sources and health plan

Community Engagement Navigator – Behavioral Health

Consultant

• Supports Employee Assistance Program (EAP) service department by responding to initial customer contacts and request for services
• receives client request, assesses situation, determines appropriate course of action
• Provides telephone and/or on-site support for crisis intervention, assessment, short term problem resolution and referral to appropriate provider(s)
• Manages Critical Incident Stress Debriefing requests
• Assesses members and assists them in accessing behavioral healthcare benefits available under their health plan
• Applies specialized knowledge in substance abuse, domestic abuse, grief counseling, workplace problems, and management consultation
• Provides employer consultation to supervisors, managers, and Human Resources of the EAP contracted organization
• Manages shared mailbox that is used by clients and external vendor to forward information that must be reviewed and placed in documentation system

Behavioral Health EAP Consultant II

Analyst

• employs advanced analytics to gain critical insights into member and/or provider behavior drivers and preferences
• consults business leaders and internal partners to apply the insights to test and drive provider innovation and enhancement
• targets the right provider partners to ensure the members receive the right high quality service
• measures program outcomes and demonstrates value
• helps win and retain clients and supports information-based strategic decision-making
• provides analytical insights to support business solution development based on quality, use, cost, and other key drivers
• develops and refines analysis templates for problem diagnosis and opportunities assessment
• contributes to the design of new programs/initiatives based on test/pilot outcomes
• proactively collaborates with business partners to determine identified population segments
• trend analytics to identify patterns and predict future trends related to value based payment data, and healthcare costs
• provides analytical support for network strategies
• conducts in-depth research to address challenging issues in measuring outcomes

Network Cost of Care Analyst, Consultant

Medical Director

• responsible for appeal reviews for physical health medical services
• developing and implementing quality improvement programs
• provide clinical consultation
• identify cost of care opportunities
• conduct peer-to-peer clinical case reviews
• serve as a resource and consultant for other areas of the company

Appeals Medical Director – Oncology

Manager

• Manages the lifecycle of payor contracts including review, interpretation, implementation, amendments, and renewals
• Serves as subject matter expert on contract terms including reimbursement methodologies, fee schedules, carve-outs, drug-level pricing, site-of-care requirements, and network participation
• Tracks contract expirations, renewals, and amendments to ensure uninterrupted access and compliance
• Analyzes reimbursement methodologies and identifies reimbursement risks, underpayments, and revenue leakage
• Partners with finance and revenue cycle to resolve reimbursement discrepancies and payment disputes
• Translates contract terms into operational requirements for pharmacy systems, billing platforms, and claim adjudication logic
• Supports payor mapping tied to configurations
• Ensures contracts comply with federal and state regulations; maintains audit-ready documentation; and supports internal/external audits
• Acts as the primary contract resource for internal teams

Payor Contract Manager, Specialty Pharmacy

• Lead and support affiliate-to-affiliate contracting activities
• Collaborate closely with Legal to interpret contract language
• Facilitate negotiations between affiliated entities
• Develop, structure, and document contractual arrangements
• Identify and mitigate contractual risks
• Serve as a key liaison between business, legal, and operational teams

Senior Business Change Manager

• Acts as a troubleshooter in resolving payor departmental issues related to credentialing
• Manages and maintains pharmacy license tracking tool to advise pharmacy sites and pharmacists of license renewals
• Maintains confidentiality of all pertinent pharmacy and provider information
• Administers credentialing and re-credentialing to ensure compliance with regulatory, accreditation and various managed care plan policies and protocols, standards, and requirements
• Develops and fosters collaborative relationships with managed care plans, state agencies and PBM’s to facilitate timely credentialing and re-credentialing of applications
• Tracks credentialing and re-credentialing to ensure compliance with time sensitive materials
• Maintains all pharmacy site credentialing and re-credentialing files, electronic and paper
• Effectively communicates with admission, billing, and clinical teams in a professional manner
• Reviews all credentialing policies and procedures for accuracy and completeness
• Suggests revisions of policies and procedures when necessary
• Completes new Medicaid applications and renewals or revalidations
• Medicaid portal maintenance and updates
• Medicaid administrator user access for billing
• Pull Medicaid remits for billing team upon request if portal access is limited
• Manage PBM credentialing requests and maintenance
• Medicare (PECOS) processing for all pharmacy sites
• Maintain NCPDP profile for all pharmacy sites
• Certificate of Insurance requests and dissemination to plans or CMS
• NPI profile updates (NPPES)
• URAC, ACHC, NABP support during accreditation renewals
• Fraud, Waste and Abuse annual attestation submission to health plans
• Manage pharmacy Continuing Education Units for RFP’s
• Pull and maintain credentialing documents for payor applications
• Submit new pharmacy license applications and renewals for all pharmacy sites
• Submit Pharmacist in Charge state license changes and renewals
• Additional responsibilities as assigned

Credentialing Analyst, Clinics

• Serves as a resource for medical management programs
• Identifies and recommends revisions to policies/procedures
• Ensures staff adheres to accreditation guidelines
• Supports quality improvement activities
• May assist with implementation of cost of care initiatives
• May attend meetings to review UM and/or CM process and discusses facility issues
• Hires, trains, coaches, counsels, and evaluates performance of direct reports
• Manages a team of licensed clinicians and non-clinical support staff to ensure medical necessity and appropriateness of care for inpatient/outpatient BH services
• Engages in telephonic outreach to members
• Monitors and evaluates the effectiveness of care plans; manages case consultation and education to customers and internal staff for efficient utilization of BH services.

Manager, Behavioral Health Services

Account Executive

• Responsible for all sales activities in a specified territory
• Builds and maintains relationships with key customers
• Works with leadership to develop territory sales forecasts and goals
• Qualifies opportunities in the territory with private insurance and/or federal or state funded plans
• Identifies and resolves customer service issues in territory
• Assists customer service and provides necessary information to meet customer’s needs
• Networks with industry partners
• Partners with appropriate team members, leadership, and other principals to close deals and negotiate deliverables
• Assesses and reports on competitive sales activities
• Represents region appropriately in sales efforts

Hemophilia Account Executive

• Develops responses for complex Requests for Proposals (RFPs)
• Organizes strategy meetings with senior sales personnel
• Writes and proofreads final deliverables
• Develops targeted Executive Summaries
• Oversees the entire production process
• Manages each project to completion
• Engages in ongoing communication with various corporate personnel
• Researches and gathers supporting materials and documentation

Proposal Development Consultant

Account Manager

• Establishes relationships and engages with BH providers and ensures measurable improvements in clinical and quality outcomes for members
• Implements strategies that meet clinical, quality, and network improvement goals
• Meets routinely with strategic providers face to face, telephonically, and via Web-Ex to support provider training on Carelon processes, contracting / credentialing and linkages for issue resolution
• Analyzes provider reports pertaining to cost, utilization, and outcomes, and presents the data to providers and highlights trends

Behavioral Health Community Partnership Manager

• Establishes relationships and engages with BH providers and ensures measurable improvements in clinical and quality outcomes for members.
• Builds relationships with internal clinical and quality departments to ensure high-quality care to members and achievement of company HEDIS performance.
• Implements strategies that meet clinical, quality, and network improvement goals.
• Build positive working relationships with providers, state agencies, advocacy groups, and other market stakeholders.
• Meets routinely with strategic providers face to face, telephonically, and via Web-Ex to support provider training on Carelon processes, contracting/credentialing and linkages for issue resolution, helping to improve provider experience and overall satisfaction with Carelon.
• Acts as a liaison between strategic providers and Carelon clinical, quality, provider strategy, operations, and claims, to ensure interdepartmental collaboration and coordination of goals and priorities.
• Supports regional and corporate initiatives regarding Carelon Select Provider (CSP) program, clinical innovation, and thought leadership transforming provider relationships from transactional interactions to collaboration.
• Creates and maintains linkages between providers of all levels of care, as well as other community-based services and resources to improve transitions of care and continuity of services.
• Partners with network providers and Carelon stakeholders to operationalize innovative programs and online resources to improve clinical and quality outcomes.
• Analyzes provider reports pertaining to cost, utilization, and outcomes, and presents the data to providers and highlights trends.
• Identifies data outliers and opportunities for improvement for individual providers.
• Identifies high-performing and innovative providers who may be interested in new programmatic incentives or payment models.
• Participates in the identification of opportunities for expansion and development of innovative pilot programs, implementation, launch, and efficacy and outcomes measurements.
• Provides consultation to providers for clinically complex members as applicable.
• Surfaces clinical and quality issues to regional clinical and quality teams and participates in helping to address concerns.
• Conducts quarterly physician record reviews or as needed with network providers across all service levels.
• Assists with provider orientations and provider training events in the region, when applicable.
• Attends all accessible County BH provider meetings either in person or via telephone or Web-ex.

AI Engineer

• build and scale reusable AI capabilities across the enterprise
• define the technical foundation for reliable, governed, and scalable AI systems
• operate at the intersection of AI engineering, platform development, and responsible AI governance
• recommend solutions to new and complex problems
• collaborate with a multi-disciplinary team of clinicians, engineers, and researchers
• design and build reusable AI platform capabilities
• develop and operationalize robust pipelines for experimentation, benchmarking, and model comparison
• define and standardize schemas, APIs, and workflows
• improve reliability, reproducibility, and quality through structured experimentation
• partner with cross-functional teams to translate use cases into production-ready, reusable capabilities
• optimize AI systems for performance, scalability, and cost efficiency
• embed Responsible AI principles by implementing governance, evaluation standards, and audit-ready processes

Senior AI Engineer

• managing psychiatric and substance abuse or substance abuse disorder facility-based and outpatient professional treatment health benefits through telephonic or written review
• Uses appropriate screening criteria knowledge and clinical judgment to assess member needs to ensure access to medically necessary quality behavioral healthcare in a cost effective setting in accordance with UM Clinical Guidelines and contract
• Refers cases to Peer Reviewers as appropriate
• Performs psychiatric and substance abuse or substance abuse disorder assessment coordination implementation case planning monitoring and evaluating to promote quality member outcomes to optimize member health benefits and to promote effective use of health benefits and community resources
• Assists with more complex cases and may participate in inter and intradepartmental teams projects and initiatives

Behavioral Health Care Manager II – BCBA/LBA, Georgia Licensed

Bilingual

• Provides primary and urgent health care via telephone and tele video modalities to patients
• Collaborates with company physicians, the patient’s other physicians and providers
• Develops complex plans of care in accordance with the patient’s health status
• Educates patients and families about medication usage and crisis anticipation
• Maintains contact with other clinical team members and medical providers
• Participates in continuing education as required by state and certifying body
• Prescribes medication as permitted by state prescribing authority

Community Engagement Navigator – Behavioral Health

Behavioral Health EAP Consultant II

Network Cost of Care Analyst, Consultant

Appeals Medical Director – Oncology

Payor Contract Manager, Specialty Pharmacy

Senior Business Change Manager

Credentialing Analyst, Clinics

Manager, Behavioral Health Services

Hemophilia Account Executive

Proposal Development Consultant

Behavioral Health Community Partnership Manager

Behavioral Health Community Partnership Manager

Senior AI Engineer

Behavioral Health Care Manager II – BCBA/LBA, Georgia Licensed

Bilingual Nurse Practitioner