Elevance Health

Project Manager

• managing multiple projects of varying sizes and duration
• applying project management knowledge, skills, tools and techniques to project deliverables, processes, and systems
• coaches and mentors project team members
• determines project scope
• develops resource, risk, quality, cost, and scope management plans
• develops training plans
• develops requirements documents
• develops project approval matrix
• identifies project team training and tool needs
• defines, recommends and secures contractual agreements for services and products
• coordinates requirements, schedules implementation and post-implement plans
• develops service-level agreements for vendor partners and global resources firms
• defines quality gates for each project methodology phase
• defines critical success factors
• establishes and manages the project warranty period

Senior Project Manager

Bilingual

• Collaborating with company providers and their family members to develop complex plans of care.
• Providing clinical and non-clinical support to patients presenting with acute care needs virtually.
• Provides urgent health care via telephone and tele video modalities.
• Developing and implementing clinical plans of care for adult patients facing chronic and complex conditions.
• Gathers history and physical exam and diagnostics as needed, then develops and implements treatment plans.
• Identifies and closes gaps in care.
• Meets the patient’s and family’s physical and psychosocial needs.
• Educates patients and families about medication usage, side effects, illness progression, diet and nutrition, medical adherence and crisis anticipation and prevention.
• Maintains contact with clinical team members and medical providers to coordinate optimal care.
• Maintains patient medical records and medical documentation consistent with regulations.
• Participates in continuing education as required by state and certifying body.
• Prescribes medication as permitted by state prescribing authority.

Bilingual Nurse Practitioner

Analyst

• Ensures accurate adjudication of claims, by translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria.
• Review medical record documentation in support of Evaluation and Management, CPT, HCPCS and ICD-10 code.
• Reviews company specific, CMS specific, and competitor specific medical policies, reimbursement policies, and editing rules, as well as conducting clinical research, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy.
• Translates medical policies into reimbursement rules.
• Performs CPT/HCPCS code and fee schedule updates, analyzing each new code for coverage, policy, reimbursement development, and implications for system edits.
• Coordinates research and responds to system inquiries and appeals.
• Conducts research of claims systems and system edits to identify adjudication issues and to audit claims adjudication for accuracy.
• Perform pre-adjudication claims reviews to ensure proper coding was used.
• Prepares correspondence to providers regarding coding and fee schedule updates.
• Trains customer service staff on system issues.
• Works with providers contracting staff when new/modified reimbursement contracts are needed.

Med Coding Appeals Analyst

Risk

• Oversee day-to-day operations and strategic execution of enterprise risk adjustment programs
• Assist management overseeing risk adjustment programs including claims, vendor quality, and audits
• Develop metrics, policies, and procedures for validation of programs return on investment
• Collaborate with operations risk and compliance teams for implementing initiatives
• Provide oversight and ensures accurate coding for Medical Revenue Management programs
• Serve as a subject matter expert on coding
• Work collaboratively with Enterprise Risk Adjustment team, Business Operations, Regulatory Compliance, and Internal Audit
• Influence others and work effectively to develop relationships with stakeholders

Risk Adjustment Strategic Manager

Underwriter

• Calculates renewal rates for large complex cases based on thorough analysis of experience, location, demographics, etc.
• Determines and provides guidance to medical underwriters concerning the risk selection of applicants applying for individual health coverage.
• Coordinates with other departments to ensure accuracy and consistency of overall account reporting.
• Proposes rates for prospective business utilizing a combination of other carrier experience, demographic data and manual rates.
• Performs post-sale reviews.
• Prepares or supervises preparation of annual settlements, ERISA reports, rate projections, or benefit change increments and decrements.
• Surveys existing product portfolios by market, monitors sales results, trends and needs, recommends product portfolio changes.
• Assists in establishing rating and administrative procedures.
• Participates in major multi-functional teams as underwriting representative.
• Assists in the technical development of underwriting associates.

Group Underwriting Consultant

Business Analyst

• Analyzes business needs to determine optimal means of meeting those needs
• Determines specific business application software requirements to address specific business needs
• Works with programming staff to ensure requirements will be incorporated into system design and testing
• Acts as liaison with users of the software to address questions/issues

Business Analyst II

• Provide non-clinical review and analysis of all non-complex and some complex Tier I post service medical claims
• Utilize guidelines and review tools to analyze assigned claims and medical records
• Approve or summarize and route claims to nursing and/or medical staff
• Serve as a liaison between medical management and/or service operations and other internal departments
• Serve as an internal resource for associates

Medical Review Analyst II

• responsible for the interpretation and data entry of moderately complex prescriptions
• prior authorization processing
• troubleshooting adjudication issues
• verifies member information and inputs data for the pharmacists
• educates members on pharmacy based rules related to prescriptions and medication resources or assistance programs
• processes prior authorization requests from physician’s offices and ensures compliance with Medicare requirements
• informs relevant parties of all prior authorization determinations
• provides resolution to grievances and appeals issues
• responds to inquiries from physicians, sales team, and members related to formulary and prescription benefits
• generates reports relating to rebates, physician utilization, Beers Criteria, Reliance members, and other ad hoc reports
• maintains record keeping of prior authorizations, rebates, and monthly reports

Pharmacy Tech II – Bilingual

Data Analyst

• Work location - Hybrid 1 This role requires associates to be in-office 1 - 2 days per week
• Researches and synthesizes detailed clinical data related to pharmaceuticals
• Proactively identify utilization management (UM) strategies that enhance the member experience while delivering positive financial outcomes
• Analyze prior authorization (PA) data and trends to develop recommendations, considering rebates, member impact, and operational efficiency
• Monitor and evaluate UM performance to ensure effectiveness and alignment with organizational goals
• Report on PA performance metrics to support data-driven decision-making across teams
• Forecast the potential financial and administrative impact associated with UM initiatives
• Track the financial impact of recently implemented UM
• Build and maintain strong cross-functional relationships with Trade, Formulary, Clinical, and Actuarial teams to collaboratively develop and implement UM solutions
• Supports therapeutic class reviews and drug monograph information to the Pharmacy and Therapeutics Committee
• May review and approve or deny coverage for pharmaceuticals (as permitted by state/federal law or state/federal program contracts) based on medical necessity criteria, and coordinates with internal stakeholders or health plan medical directors as needed
• Serves as a clinical resource to other pharmacists on areas such as prospective, inpatient and retrospective DURs and provides dosage conversion and clinical support for therapeutic interventions
• Prepares information for network physicians

Clinical Pharmacist – Data Analytics

Auditor

• Examines claims for compliance with relevant billing and processing guidelines and identifies opportunities for fraud and abuse prevention and control.
• Reviews and conducts analysis of claims and medical records prior to payment and uses required systems/tools to accurately document determinations and continue to next step in the claims lifecycle.
• Researches new healthcare related questions as necessary to aid in investigations and stays abreast of current medical coding and billing issues, trends and changes in laws/regulations.
• Collaborates with the Special Investigation Unit and other internal areas on matters of mutual concern.
• Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation.
• Assists with training of new associates.

Clinical Provider Auditor II – Payment Integrity

• Ensures member access to services appropriate to their health needs
• Conducts assessments to identify individual needs and a specific care management plan
• Implements care plan by facilitating authorizations/referrals
• Coordinates internal and external resources to meet identified needs
• Monitors and evaluates effectiveness of the care management plan
• Interfaces with Medical Directors and Physician Advisors on treatment plans

Senior Nurse Case Manager, Bilingual

Manager

• Managing psychiatric and substance abuse treatment plan
• Assessing member needs and referring cases to Peer Reviewers
• Performing psychiatric and substance abuse assessment coordination

Behavioral Health Care Manager – I

Pharmacist

• Perform care management activities for members with complex and chronic care needs
• Ensure high quality, cost-effective care and appropriateness of treatment
• Partner with physicians and/or pharmacists to interpret appropriateness of care
• Collaborate with providers to assess consumer needs and plan for adverse events
• Conduct clinical assessments to develop individual care plans and goals
• Monitor and evaluate effectiveness of care management plans

Clinical Nurse Coordinator – Telephonic

Call Center Representative

• Effectively support the Subrogation Recovery Operations team
• Provides exceptional service to member, providers, group administrators and attorneys
• Identifies, reviews, sets up or closes health insurance subrogation claims via phone, fax, email or mail
• For open cases, collects, records and verifies member information, pertinent accident details, attorney information and third-party liability information
• Records detailed and accurate file notes obtained from calls or written correspondence
• Manage high-volume intake calls and correspondence inventory effectively
• Determine membership eligibility using various job aids and membership systems
• Responds to calls, letters, faxes and emails from policyholders, agents, vendors and/or providers
• Show initiative and resourcefulness in solving problems and meeting customer needs
• Develop relationships with other business units and service partners
• Adheres to company and department policies and procedures as well as HIPAA regulations
• Performs other duties as requested or assigned

Senior Project Manager

Bilingual Nurse Practitioner

Med Coding Appeals Analyst

Risk Adjustment Strategic Manager

Group Underwriting Consultant

Business Analyst II

Medical Review Analyst II

Pharmacy Tech II – Bilingual

Clinical Pharmacist – Data Analytics

Clinical Provider Auditor II – Payment Integrity

Clinical Provider Auditor II – Payment Integrity

Senior Nurse Case Manager, Bilingual

Behavioral Health Care Manager – I

Clinical Nurse Coordinator – Telephonic

Recovery Specialist Associate – Call Center