Elevance Health

Bilingual

• Provides urgent health care via telephone and tele video modalities to patients
• 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
• Educates patients and families about medication usage, side effects, illness progression, diet and nutrition, medical adherence and crisis anticipation and prevention
• Maintains contact with other clinical team members and other medical providers to coordinate optimal care
• Maintains patient medical records and medical documentation consistent with state regulations and company standards
• Participates in continuing education as required by state and certifying body
• Prescribes medication as permitted by state prescribing authority

Nurse Practitioner, Bilingual, 100% Virtual

Medical Director

• responsible for the appeal reviews for physical 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

Medical Director – Oncology

Sales

• Drives profitability at the district and infusion centers level by effectively leading frontline associates
• Manages sales activities to produce desired sales results established leadership
• Manages the profitability within the budget of their district by maximizing profitable revenue, staffing levels and sales expenses while maximizing patient growth
• Works closely with the Center Operations Managers (COMs) and regional leadership to ensure the highest quality of support for patients
• Monitors progress in meeting established objectives
• Ensures optimum coverage for all customers and potential customers
• Completes customer contact and market reports and informs leadership on market changes
• Forecasts sales performance
• Ensures effective distribution of products in the district including adequate stocking and adequate coverage of all distribution channels
• Travels extensively
• Hires, trains, coaches, counsels, and evaluates performance of direct reports

District Sales Manager – Hemophilia

Account Manager

• Provide quality, accessible and comprehensive service to the company's provider community
• Develop and maintain positive provider relationships through visits and communications
• Research, analyze, and coordinate resolution to complex provider issues
• Collaborate with internal partners to triage issues
• Coordinate Joint Operation Committees
• Conduct proactive outreach on managed care policies
• Participate in external Provider Townhalls/Seminars

Provider Relationship Account Manager

Manager

• Responsible for care management for members with complex and chronic care needs
• Assess, develop, implement, coordinate, monitor, and evaluate care plans
• Ensure member access to services appropriate to their health needs
• Conduct assessments to identify individual needs
• Implement care plan by facilitating authorizations/referrals
• Coordinate internal and external resources to meet identified needs
• Monitor and evaluate effectiveness of care management plan
• Interface with Medical Directors and Physician Advisors on treatment plans
• Assist in problem solving with providers and service issues
• Help in developing utilization/care management policies and procedures

Telephonic Nurse Case Manager II

• Responsible for the administration of physical and/or behavioral health medical services
• Supports clinicians to ensure timely and consistent responses to members and providers
• Conducts peer-to-peer clinical reviews
• Identifies and develops opportunities for innovation to increase effectiveness and quality

Medical Director – Family/Internal Medicine

Operations

• Serves as the primary Medicare pharmacy benefit SME, partnering with health plan product, clinical, and PBM/vendor teams
• Leads end-to-end benefit build lifecycle including documentation, CMS submission support, configuration logic, testing, validation, and promotion to production
• Identifies potential issues, impacts to adjudication logic, and scope changes
• Leads efforts to identify and implement best practices related to Medicare pharmacy benefit design
• Develops and designs processes and systems for accurate benefit setup
• Designs methods for integrating benefit configuration processes across systems
• Provides process, project, and change management methodology coaching/consulting support
• Leads prioritization and execution of benefit-related initiatives tied to CMS deadlines

Business Change Director – CarelonRx PBM Operations Management

• Responsible for managing psychiatric 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
• Refers cases to Peer Reviewers as appropriate
• Conducts psychiatric disorder assessment coordination implementation case planning monitoring and evaluating to promote quality member outcomes
• Assists with more complex cases and may participate in inter and intradepartmental teams’ projects and initiatives

Behavioral Health Care Manager II

Analyst

• Reviews and evaluates accident or incident reports, individual claims, medical, legal or other documents relating to subrogation.
• Responds to inquiries regarding claim recovery issues.
• Identify, monitor and evaluate claim data to determine relatedness and reimbursement amounts.
• Analyze, interpret and apply plan language, contracts, case law and various statutes or regulations.
• Prepares and maintains case files, correspondence, legal documents and other information related to subrogation claims.
• Coordinates actions involving accounting for payments received.
• Evaluates and negotiates settlements of subrogation claims of all dollar amounts within a prescribed level of authority.

Subrogation Analyst

• Completing medical necessity reviews for substance use disorder cases
• Supporting clinicians for timely responses to members and providers
• Providing clinical operational guidance
• Conducting peer-to-peer clinical reviews

Medical Director – Addiction Medicine

Underwriter

• Underwrites and prices complex large group new business
• Calculates renewal rates for large complex cases
• Provides guidance to medical underwriters
• Coordinates with other departments for accuracy
• Proposes rates for prospective business
• Performs post-sale reviews
• Prepares annual settlements, ERISA reports, and rate projections
• Surveys existing product portfolios and monitors trends
• Assists in establishing rating and administrative procedures
• Participates in major multi-functional teams as underwriting representative
• Monitors departmental processes in compliance with requirements

Group Underwriting Consultant

Auditor

• identifying issues and/or entities that may pose potential risk associated with fraud and abuse
• 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

Clinical Provider Auditor I

Data Engineer

• Work with datasets of varying size and complexity, including structured and unstructured data, and process massive data streams through ETL/ELT, metadata extraction, dataset registry, cohort development, and data enrichment/merging to enable advanced analysis.
• Analyze how partners use data and technology solutions to generate intelligence that enhances product development and enablement, while designing, codifying, and advising partners on effective product utilization to ensure objectives are achieved.
• Guide the creation of high-quality assets that increase the value and differentiation of data and technology products, and partner with product and engineering to package and operationalize methods while enhancing products with advanced computation and expanded analytic tech stacks (e.g., LLM co-piloting, natural language prompting, and no/low-code integrations).
• Partners with product managers to achieve superior execution of product strategy in the marketplace.
• Tracks individual product performance by benefit design, market segment and sub region.
• Supports the development of short and long term strategic product plans in support of market, sales and profitability objectives.
• Identifies system needs to support short and long term product strategy.
• Develops system requirements and ROI.
• May lead effort or manage project teams in the implementation of complex regional and companywide initiatives including portfolio repositioning in a market, legislative changes, network/provider changes/ medical management program and policy initiatives, etc.
• Develops, implements and maintains competitive product platform.

Senior Product Management Director – Data Platforms

General Counsel

• Provide legal guidance on a range of health law, regulatory, contractual and operational matters
• Work as a strategic partner with assigned clients and provide legal advice and guidance on business strategies or various corporate initiatives
• Proactively assist provider contracting staff managing a behavioral health network with legal issues that arise during contract negotiations
• Review proposed contract language changes and draft alternatives to protect the company's interests
• Support development and roll-out of new provider contract templates
• Assist with responding to regulatory inquiries or complaints
• Support value-based contracting and negotiation of shared savings or risk arrangements
• Prepare settlement agreements, letters of intent, confidentiality agreements and other documents as needed

Senior Legal Counsel

• 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
• conducting assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment
• implementing care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements
• coordinating internal and external resources to meet identified needs
• monitoring and evaluating effectiveness of the care management plan and modifying as necessary
• interfacing with Medical Directors and Physician Advisors on the development of care management treatment plans
• negotiating rates of reimbursement, as applicable
• assisting in problem solving with providers, claims or service issues