Elevance Health

General

• Determines and provides guidance to medical underwriters concerning the risk selection of applicants applying for commercial 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
• Works with product and sales partners to survey existing product portfolios by market, monitors sales results, trends and needs and recommends product portfolio changes

Senior Group Underwriter

Pharmacist

• 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 (AWP, WAC, ASP, MAC, per diem, case rates, nursing fees, supplies, admin fees) and identifies reimbursement risks, underpayments, and revenue leakage.
• Partners with finance and revenue cycle to resolve reimbursement discrepancies and payment disputes and supports forecasting, margin analysis, and payor profitability reporting.
• Translates contract terms into operational requirements for pharmacy systems, billing platforms, and claim adjudication logic and coordinates with IT and pharmacy operations to ensure accurate setup of pricing and payor-specific rules (including NDC requirements, J-codes, modifiers, and site-of-care billing logic).
• Supports payor mapping tied to BIN/PCN, NCPDP, NPI, and taxonomy configurations.
• Ensures contracts comply with federal and state regulations including CMS, Medicare Part B and D, Medicaid, 340B, and anti-kickback requirements; maintains audit-ready documentation; and supports internal/external audits.
• Acts as the primary contract resource for internal teams; provides contract education to support accurate billing and payor compliance; and supports payor escalations, access issues, and network participation inquiries.

Payor Contract Manager – Infusion

Manager

• Responsible for conducting service coordination functions for a defined caseload of individuals in specialized programs.
• Facilitates the Person Centered Planning process that documents the member’s preferences, needs and self-identified goals.
• Conducts assessments, development of a comprehensive Person Centered Support Plan (PCSP) and backup plan.
• Interfaces with Medical Directors and participates in interdisciplinary care rounds to support development of a fully integrated care plan.
• Engages the member’s circle of support and overall management of the individuals physical health (PH)/behavioral health (BH)/LTSS needs, as required by applicable state law and contract, and federal requirements.
• Performs face to face program assessments for identification.
• Applies motivational interviewing techniques for evaluations, coordination, and management of an individual’s waiver (such as LTSS/IDD), and BH or PH needs.
• Uses tools and pre-defined identification process to identify members with potential clinical health care needs and coordinates those member’s cases with the clinical healthcare management and interdisciplinary team in order to provide care coordination support.
• Manages non-clinical needs of members with chronic illnesses, co-morbidities, and/or disabilities, to ensure cost effective and efficient utilization of long-term services and supports.
• Documents members' short and long-term service and support goals in collaboration with the member’s chosen care team.
• Identifies members that would benefit from an alternative level of service or other waiver programs.
• May also serve as mentor, subject matter expert or preceptor for new staff, assisting in the formal training of associates, and may be involved in process improvement initiatives.
• Submits utilization/authorization requests to utilization management with documentation supporting and aligning with the individual’s care plan.
• Responsible for reporting critical incidents to appropriate internal and external parties such as state and county agencies (Adult Protective Services, Law Enforcement).
• Assists and participates in appeal or fair hearings, member grievances, appeals, and state audits.

LTSS Service Coordinator, Case Manager – Region F

Consultant

• 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
• Consults on all considerations related to designing and executing tests or pilot programs
• Contributes to the design of new program/initiative based on test/pilot outcomes
• Develops targeting criteria or customer segmentation based on analytical insights
• Develops predictive models and other tools that help target the right members
• Develops methodology to measure clinical, utilization and financial outcomes
• Conducts in-depth research to address challenging issues in measuring outcomes
• Leads applied research projects; authors white papers, presents at industry conferences and submits journal publications
• Addresses limitation of certain data sources and evaluates incremental value of new data sources
• Managing custom ASO client business definitions thru Rule committee approval, intake submission, and implementation on rules engine
• Produce custom financial models for ASO clients to support impact analysis of operational errors and potential refunds
• Support multiple new strategic projects such as Agora, NCPDP F6, AI BI, etc

Advanced Analytics Consultant

• Responsible for conducting service coordination functions for a defined caseload of individuals in specialized programs
• In collaboration with the person supported, facilitates the Person Centered Planning process that documents the member’s preferences, needs and self-identified goals
• conducting assessments, development of a comprehensive Person Centered Support Plan (PCSP) and backup plan
• interfacing with Medical Directors and participating in interdisciplinary care rounds to support development of a fully integrated care plan
• engaging the member’s circle of support and overall management of the individuals physical health (PH)/behavioral health (BH)/LTSS needs
• Responsible for performing face to face program assessments for identification
• applying motivational interviewing techniques for evaluations, coordination, and management of an individual’s waiver
• Uses tools and pre-defined identification process, identifies members with potential clinical health care needs
• coordinates those member’s cases with the clinical healthcare management and interdisciplinary team
• Manages non-clinical needs of members with chronic illnesses, co-morbidities, and/or disabilities
• Assists and participates in appeal or fair hearings, member grievances, appeals, and state audits

LTSS Service Coordinator – Case Manager

• Responsible for performing case management telephonically and/or by home visits
• Responds to more complex cases and account specific requests
• Uses appropriate screening criteria knowledge and clinical judgment to assess member needs
• Conducts assessments to identify individual needs and develops specific care plan
• Monitors and evaluates effectiveness of care plan and modifies plan as needed
• Supports member access to appropriate quality and cost effective care
• Coordinates with internal and external resources to meet identified needs

Behavioral Health Case Manager II

Representative

• Drives members/patients back and forth to their health service centers
• Contacts the affiliate to confirm the coordinated service
• Contacts the member to report they are near the pickup location
• Follows up on the service provided, making changes in the status of services in the platform, to ensure effective monitoring and compliance, and guarantee quality service
• Associates in this role are expected to be able to work independently, be punctual, have attention to details, be empathetic to the situations of others and have strong communication and customer service skills
• Drive long distances more than 3 days a week

Patient Transportation Representative

Data Engineer

• Leads the architecture, engineering, and ongoing operation of the security data lake and associated data products supporting multiple security technologies and data sources
• Establishes the technical roadmap, engineering standards, reusable design patterns, and platform operating model
• Acts as a subject matter expert among peers, with manager and senior management on all matters pertaining to data platforms and the supporting architecture
• Develop and maintain the end-to-end architecture of the security data lake, including ingestion, storage, transformation, enrichment, semantic, and consumption layers
• Ensure data pipelines comply with security policies and regulatory requirements
• Develop testing plans to ensure quality of implementation
• Provide trouble resolution on complex problems and lead implementations for data pipelines, Microsoft Fabric, Azure DevOps, REST API, and source-system integration issues
• Maintain relationship with key vendors
• Create presentations and seek IT management approval and acceptance of significant replacements or reconfigurations of the data pipeline

Senior Data Engineer

Analyst

• Responsible for accurate and prompt credentialing for health plans and pharmacy benefit managers (PBM).
• 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.
• Manages PBM credentialing requests and maintenance.
• Medicare (PECOS) processing for all pharmacy sites.
• Maintains 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.

Credentialing Analyst – Infusion Clinics

• Analyze attribution, affinity, membership, claims, provider, and utilization data to identify trends, patterns, anomalies, and business impacts
• Serve as a primary contact for Markets, Advisors, and business partners for ad hoc inquiries related to attribution, membership, provider alignment, and performance metrics
• Develop, maintain, and enhance recurring reports, dashboards, and data extracts
• Investigate and resolve data quality issues, including attribution discrepancies, membership inconsistencies, and provider population variances
• Collaborate with business, IT, and data engineering teams to implement new reporting capabilities and improve existing processes
• May lead teams of analysts assigned to complex projects
• Determines specific business application software requirements to address complex and varied business needs
• Analyzes and designs solutions to address complex and varied business needs
• Consults with business partners concerning application and implementation of technology

Business Consultant

Security Analyst

• Independently assess, document, and monitor cybersecurity risks with third-party vendors
• Evaluate vendor security controls and review assurance evidence
• Communicate directly with vendors for validations and risk mitigation activities
• Lead cybersecurity risk assessments and due diligence reviews
• Develop testing plans and coordinate reporting of data security incidents
• Provide technical support in risk assessments and implementing security procedures

Senior Third Party Cybersecurity GRC Analyst

Health Coach

• Conducts behavioral assessments to identify individual member knowledge, skills, and behavioral needs
• Coordinates specific health coaching as directed by nurse case manager
• Implements coaching plan by using behavior change principles to identify member barriers
• Coordinates with the nurse case manager to provide feedback on member goal attainment
• Monitors and evaluates the interventions and modifies

Psychologist

• Responsible for collaborating with providers and Medical Directors to determine appropriateness of level of care based on Medical Necessity Criteria
• May be called upon to review other outpatient levels of care including: Individual Therapy, Group Therapy, Family Therapy, Marriage/Couples Therapy, Psychological Testing, Neuropsychological Testing, Psychosocial Rehabilitation, Intensive Outpatient Treatment, Day Treatment, and Mental Health Support Services
• Serve as a subject matter expert collaborating with plan leadership, providers and other stakeholders to enhance the delivery of service for Autism Spectrum Disorder
• Partners with internal UR staff and external Behavioral Health Providers to ensure appropriate and consistent utilization of plan benefits, out of network services, and clinical guidelines within scope of license
• Conducts pre-certification, concurrent review, and appeals of Behavioral Health OP services
• Mentors Behavioral Health Care Management staff by assisting in training, attending utilization management rounds, and serving on interdepartmental initiatives; assists in developing a program around psychological and neuropsychological testing

Psychologist Reviewer – Part Time

• Manage and oversee coordination of a comprehensive health care program
• Ensure appropriate delivery of care to members
• Coordinate service delivery including member assessment
• Participate in cross-functional workgroups
• Evaluate and recommend changes for increased efficiencies
• Develop and conduct training programs for staff
• Extract and manipulate analytical data for findings presentation
• Hire, train, coach, counsel, and evaluate performance of direct reports

Manager I – GBD Special Programs

• Managing and overseeing team responsible for coordination of a comprehensive healthcare program
• Identifying member needs in physical health, behavioral health, social services
• Coordinating service delivery including member assessment
• Participating in cross-functional workgroups
• Evaluating current processes and recommending changes
• Developing and conducting training programs
• Extracting and manipulating analytical data