Elevance Health

Systems Engineer

• Builds and maintains strong relationships with Business and IT partners
• Identifies opportunities to support business activities
• Leads the high-level requirements development process
• Supports elicitation/development of detailed business requirements for small- to medium-sized efforts
• Partners with Account Managers collaborating on business opportunities and solutions
• Supports development of customer strategy plans and technology solutions to meet business requirements
• Anticipates and identifies customer needs and matches products and services to facilitate the fulfillment of those needs

Senior IT Business Systems Analyst

Manager

• Oversees department to meet or exceed departmental goals and staying within budget
• Develops performance-based metrics to facilitate measurement of staff productivity
• Develops and document process flows and policies for the department
• Ensures processes are in line with contracts and the strategic vision of the organization
• Determines root causes of contractual deficiencies
• Performs quality assurance functions to ensure monitoring controls are in place and valid
• Initiates action plans to resolve issues
• Serves as primary department liaison for activities in state, federal and organizational audits
• Reviews and responds to contract proposals
• Performs project management functions in achieving the timely completion of deliverables

Manager II – Process Excellence

Billing Specialist

• Maintains billing system database
• identifies, analyzes and reconciles discrepancies in data
• posts to sub ledgers
• coordinates account eligibility with Membership areas
• provides billing information to internal and external contacts
• first line collections
• Professional and timely oral or written communication to internal and external customers
• Fully proficient with daily tasks

Senior Billing Specialist

Program Manager

• Provide program management supporting LTSS HEDIS and quality activities across Medicaid LTSS markets
• Support end-to-end LTSS HEDIS operations, including data collection, validation, reporting, and audit readiness in alignment with contractual and regulatory requirements
• Support LTSS markets in maintaining compliance with NCQA LTSS Distinction standards and evolving CMS HCBS Quality Measure Set requirements under the Medicaid Access Final Rule
• Support LTSS HEDIS data logic, mapping, and measuring specifications, accounting for state-specific assessment tools, systems, and contractual nuances
• Partner with internal stakeholders and market teams to ensure accurate, timely, and compliant LTSS quality reporting aligning audit and performance teams across all participating states
• Support annual LTSS HEDIS audits, including review and oversight of member record reviews, IRR reviews, and overreads
• Support implementation and integration of new LTSS quality measures, assessing operational impact, data availability, validation requirements, and audit implications
• Identify risks related to compliance, data integrity, audit readiness, and operational capacity, and proactively develop mitigation strategies
• Drive process improvement, documentation, and standardization to improve consistency, efficiency, and quality outcomes across markets
• Provide backup coverage and business continuity for the LTSS COE Quality Program Director
• Develop and deliver training, guidance, and technical support to markets and internal teams on LTSS Quality requirements and best practices
• Monitor regulatory changes and emerging requirements to ensure the LTSS COE remains proactively compliant and audit-ready
• Support continuous quality improvement initiatives to strengthen quality performance, member surveys, state evaluations, and contract compliance

Program Manager – LTSS

Director

• Manages the prioritization and development of reports for business reporting and analysis purposes
• Oversees the development and execution of new and innovative initiatives
• Manages rising costs and enhances market competitiveness
• Identifies and develops best practices around network strategies and clinical efforts
• Oversees identification of affordability opportunities through trend analytics review

Healthcare Cost Outcomes Director

Robotics

• Works with business partners for process identification and feasibility, solving issues that arise in day to day running and providing timely responses and solutions as required
• Performs Proof of Concepts to help the business recognize the feasibility of an automated solution
• Leads structured peer reviews and walkthroughs
• Creates and maintains automations that will interact with multiple internal and external applications
• Participates in the technical design and development including creating and maintaining solution documentation
• Engages cross-functional team members effectively to develop high quality products
• Maintains and improves existing applications by working closely with business stakeholders to map existing work processes and identify productivity opportunities
• Ensures best practices are being followed at each stage of development and test procedures and scenarios

Business Process Automation Consultant

Medical Director

• Administration of physical and/or behavioral health medical services
• Ensure appropriate and most cost effective medical care is received
• Develop and implement programs to improve quality, cost, and outcomes
• Provide clinical consultation and serve as clinical/strategic advisor to enhance clinical operations
• Identify cost of care opportunities
• Serve as a resource to staff including Medical Director Associates
• Responsible for an entire clinical program
• Supports clinicians to ensure timely and consistent responses to members and providers
• Provides guidance for clinical operational aspects of a program
• Serves as a resource and consultant to other areas of the company
• May be required to represent the company to external entities and/or serve on internal and/or external committees
• Interprets medical policies and clinical guidelines

• managing psychiatric and substance abuse treatment benefits through telephonic or written review
• assessing member needs to ensure access to quality behavioral healthcare
• coordinating, implementing, and monitoring case planning
• serving as a resource to other BH Care Managers
• assisting with complex cases and participating in projects and initiatives

Behavioral Health Care Manager II

Consultant

• quality documentation, coding and value capture
• focus on chart reviews by supplying clinical expertise to ensure full accurate and appropriate diagnosis, documentation, coding and care
• review all provider visit medical encounters and apply most appropriate diagnosis codes
• overall accountability for the HCC/Risk Adjustment of goals and workflows to support value capture initiatives and high-quality clinical documentation
• liaison to coding team
• chart reviews for closing HEDIS care opportunities to ensure practice and health plan success
• participate in peer review of medical documentation for completed visit notes and patient profile information in EMR
• review and correct any ICD-10 codes that have been assigned in charts
• provide feedback to the provider for improved documentation to support specific codes

Clinical Quality Consultant

• Develops the provider network through contract negotiations (language and rates), relationship development, and servicing
• Contracting and negotiating contract terms
• Works with less-complex to complex providers
• Drafts documents and prepares financial projections
• Works with increased independence and requires increased use of judgment and discretion

Provider Network Manager

Bilingual

• Collaborating with company providers and their family members to develop complex plans of care in accordance with the patient’s health status and overall goals and values
• Provides clinical and non-clinical support to patients presenting with acute care needs virtually
• Provides urgent health care via telephone and tele video modalities to patients who receive home and community-based services
• Develops and implements clinical plans of care for adult patients facing chronic and complex conditions
• Gathers history and physical exam and diagnostics as needed, and 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 patient medical records and medical documentation consistent with state regulations and company standards and policy
• Participates in continuing education as required by state and certifying body
• Prescribes medication as permitted by state prescribing authority

Bilingual Nurse Practitioner

• performing care management within the scope of licensure for members with complex and chronic care needs
• assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum
• performs duties telephonically with medical groups, providers, community resources, and members for discharge planning
• ensures member access to services appropriate to their health needs
• conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment
• implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements
• coordinates internal and external resources to meet identified needs
• monitors and evaluates effectiveness of the care management plan and modifies as necessary
• interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans
• assists in problem solving with providers, claims or service issues

Nurse Case Manager – California HMO

Therapist

• The Therapy Services Reviewer is responsible for the review of medical records to determine if requests for therapy services (physical therapy, occupational therapy) were medically necessary and filed appropriately.
• Follows the system guidelines that makes decisions on approval for care for a patient.
• Processes system generated decisions for authorization requests, meeting all contract requirements, processes, and operational unit goals to ensure customer satisfaction.
• Documents findings, develops analyses, and submits reports to the appropriate departments in accordance with government regulations and requirements.
• Researches and obtains additional data, consults with clinical reviewers and medical directors, when necessary.
• Acts as a resource for internal and external customers.
• May participate in intradepartmental teams, projects, and initiatives.
• Maintains quality and productivity standards and ensures reviews are conducted within required timeframes.

Physical Therapist, Occupational Therapist – Therapy Services Reviewer

• Translate highly complex business needs into application software requirements
• Provide expertise to lower-level consultants
• Analyze and design solutions to address complex business needs
• May lead teams of analysts on complex projects

Senior Business Consultant

Security Engineer

• Support a containerized IdentityIQ Deployment in AWS
• Mentor and consult with peers and customers
• Configure systems and application monitoring, defining alerts and building appropriate dashboards and documentation
• Integrate security tools, standards and processes into the Software Development Life Cycle
• Create new standards and best practices to increase effectiveness of provisioning and deprovisioning across a diverse environment
• Write and deploy code for SailPoint IdentityIQ
• Provide solutions to our customers in an effective and efficient manner
• Write documentation encompassing the configurations around any code developed including but not limited to troubleshooting, decommissioning, and other applicable facets
• Automate provisioning and integration as part of mergers and acquisitions
• Lead the development of requirements, system architecture, and software design of security products and services