Elevance Health

Clinician

• Ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies
• Confirming medical services are appropriate based on assigned benefit plan, medical policies, clinical guidelines, plan benefits, and/or scripted algorithms
• Handling less complex benefit plans and/or contracts
• Conducting and may approve precertification, concurrent, retrospective, out-of-network, and/or appropriateness of treatment setting reviews by assessing clinical information against appropriate medical policies, clinical guidelines, and the relevant benefit plan/contract
• Referring complex or non-routine reviews to more senior nurses and/or Medical Directors

Medical Management Clinician Associate

Customer Support

• Responds to internal and external customer questions via telephone and written correspondence regarding insurance benefits, provider contracts, eligibility and claims
• Analyzes problems and provides information/solutions
• Operates a PC/image station to obtain and extract information; documents information, activities and changes in the database
• Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner
• Researches and analyzes data to address operational challenges and customer service issues
• Provides external and internal customers with requested information
• Receives and places follow-up telephone calls / e-mails to answer customer questions that are routine in nature
• Uses computerized systems for tracking, information gathering and troubleshooting

Customer Care Representative I

Sales

• Provides general administrative support to the sales teams.
• Gathers, scrubs, inputs, and tracks sales data to ensure it is complete and accurate.
• Generates reports for brokers, clients and sales teams.
• Engages and fosters relationships with internal and external partners.
• Completes projects as requested by the sales teams.
• Coordinates with proposal units on request for proposal ("RFP") responses to brokers and groups and maintains various system updates for proposal and sales activity.
• Researches and resolves routine sales, claims, and benefit issues.

Sales Support Coordinator I

Representative

• Coordinating cases for precertification and prior authorization review
• Managing incoming calls or incoming post services claims work
• Determining contract and benefit eligibility
• Providing authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests
• Referring cases requiring clinical review to a Nurse reviewer
• Responding to telephone and written inquiries from clients, providers and in-house departments
• Conducting clinical screening process
• Authorizing initial set of sessions to provider
• Checking benefits for facility based treatment
• Developing and maintaining positive customer relations

Utilization Management Representative I

Reviewer

• conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines
• collaborating with healthcare providers, and members to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes, and to optimize member benefits
• working on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management
• partnering with more senior colleagues to complete non-routine reviews
• conducting medical necessity clinical screenings of preauthorization requests to assess the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment

Nurse Reviewer

General

• Responsible for developing and executing the regional sales strategy to drive the adoption and utilization of BioPlus Specialty Pharmacy for specialty medications
• Maintains sales effectiveness within the assigned territory through regular in-person meetings and support for healthcare providers and staff
• Utilizes databases, Salesforce, and other tools to identify key accounts, document sales activity, and analyze performance metrics to maximize referral potential
• Develops and fosters account relationships, ensuring effective communication and exemplary customer service
• Maintains and documents a call cycle
• Build and maintain strong relationships with key stakeholders, including providers, biologic coordinators, medical assistants, clinical teams, and pharmaceutical partners
• Supports specialty pharmacy activity, including providing educational resources and reimbursement processes
• Partners with the leadership team to formulate and execute business objectives and communicates all information about competitors, issues, and business threats
• Attends and participates in sales meetings, conferences, training programs, conventions, and engages in necessary travel within the designated region

Regional Account Liaison, BioPlus Specialty Infusion

Human Resources

• This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy.
• Responsible for researching and investigating other coverage for all of the company's groups and members on multiple platforms.
• Fully proficient in all key areas; performs multi complex functions and interprets complex rules, laws and contracts.
• Accountable for end-to-end functionality on every Coordination of Benefits(COB) function including reconciliation of claim, membership and accounting.
• Utilizes internal queries, internal resource tools, must initiate delicate-in-nature phone calls to other carriers, members, groups, providers, attorneys, CMS and Medicaid and report to identify members who are or should be enrolled in other coverage.
• Aides members in enrolling in Medicare when they are entitled.
• Determines primacy on each case using a complex set of Primacy Rules as mandated by State and Federal Laws, such as CMS Primacy and NAIC rules and comparing them against the member/groups benefits.
• Updates all of the company's membership system components with investigation results for claim coordination.
• Ensures correct forms are provided to assist members enrolling in Medicare.
• Reviews claim history to identify claims requiring reconciliation, whether processed or pended, as well as recovered in error.
• Associate must identify the correct formulas in order to adjudicates impacted claims, using multiple COB Formulas for the various product types, pursuant to State and Federal Guidelines.
• Expected to have the ability to multi-task, including handling calls, texts, facsimiles, and electronic queues, while simultaneously taking notes and speaking to customers.

eCOB Specialist II, III – Newborn Benefits

Consultant

• Conduct detailed evaluations of provider practices to determine their current capabilities in value-based care and identify key areas for growth and improvement.
• Obtain and analyze practice specific cost and quality data and reports for cost of care and quality opportunities.
• Help practice target high risk members and gaps in care based on reports provided.
• Supports practice implementation of population health management, care coordination and care management strategies.
• Identify action plans for providers to implement to improve cost, quality, and the patient experience.
• Participate in design, development, and implementation of community learning forums.
• Serve as the point of contact for providers and primary care practices for program onboarding.
• Facilitate routine meetings with the provider office.
• Serve as the subject matter expert and liaison with Care Management to facilitate clinical processes between the company and the provider office.
• Create and deliver tailored learning opportunities to aid providers in implementing recommended interventions effectively.
• Advise executives on developing segment-specific strategies in areas such as financial performance, incentive programs, quality management, and other operational areas impacting provider success.

Senior Care Consultant

Artificial Intelligence

• Translate enterprise technology and business strategies into an actionable portfolio
• Establish execution patterns for AI and automation programs
• Build and run an enterprise operating model that balances execution discipline with agility
• Build executive-grade dashboards and performance views
• Ensure clear adoption ownership and business outcomes for major initiatives
• Lead, coach, and grow SPO leaders, PMs, and execution leads

Staff Vice President – Enterprise Technology Transformation, AI Execution

Manager

• Ensure the accuracy of claims payment through management of a robust process
• Coordinate and respond to inquiries from executives
• Handle the processing and management of Payment Integrity waivers
• Assist in preparing responses to Requests for Proposals across all lines of business
• Document process flows accurately
• Help with preparing presentations
• Review and approve performance guarantees
• Evaluate regulatory compliance and Health Care Reform changes
• Monitor provisions of the compliance plan
• Develop and analyze monthly reports
• Develop project plans and oversee project execution

Payment Integrity Manager

Care Navigator

• Coordinates follow-up care plan needs for members by scheduling appointments or enrolling members in programs
• Assesses member compliance with medical treatment plans via telephone or through on-site visits
• Identifies barriers to plan compliance and coordinates resolutions
• Identifies opportunities that impact quality goals and recommends process improvements
• Recommends treatment plan modifications and determines need for additional services, in conjunction with case management and provider
• Coordinates identification of and referral to local, state or federally funded programs
• Coaches members on ways to reduce health risks
• Prepares reports to document case and compliance updates
• Establishes and maintains relationships with agencies identified in appropriate contract

Care Navigator, Transitions of Care

• Responds to incoming calls and may initiate outgoing calls, providing customer service to plan members, providers and employer groups by answering benefit questions, resolving issues and educating callers.
• Verifies enrollment status, makes changes to records, researches and resolves enrollment system rejections; addresses a variety of enrollment questions and/or concerns received by phone or mail.
• May be responsible for billing and delinquency processes for assigned groups.
• Ensures accuracy and timeliness of the membership and billing function.
• Responds to inquiries concerning enrollment processes.
• Maintains enrollment database.
• May order identification cards.
• Determines eligibility and applies contract language for each case assigned.
• Performs error output resolution for electronic eligibility and processes error discrepancy list.
• Bills, collects premiums and reconciles payments.
• Maintains and reconciles premium bill, self-bill and individual billed accounts.
• Notifies clients of premium discrepancies through payment adjustment notices and detailed audits.
• Screens all forms and data for all paperwork received from Sales and/or Underwriting for new group and/or group re-classing benefits.
• Makes request to Underwriting, Sales or Brokers for missing information and/or forms needed for new group or re-class of existing group.
• May be responsible for loading rates to new groups and renewal/re-class groups within the appropriate system.
• Screens group for benefits to determine if existing or new, recognizing when benefits are not standard and handling as appropriate.
• Thoroughly documents inquiry outcomes for accurate tracking and analysis.
• Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.

Membership Representative

• responsible for managing key components of the provider reimbursement strategy and policy
• Ensures accurate adjudication of claims
• translating various complex coding, business and billing rules and standards into effective and accurate reimbursement policies
• Serves as subject matter expert regarding reimbursement policies
• Leads policy development for specific plan(s) and/or the development and implementation of behavioral health reimbursement policy rules
• Works with the multiple business areas to ensure that accurate cost of care targets are incorporated into the company's financial plans
• Performs and/or directs complex research to ensure that projected changes meet corporate cost targets
• Prepares and presents cost of care data analysis to support the regions cost of care initiatives
• Develops and maintains the provider reimbursement policies that will lower the cost of care, improve service, and reduce administrative expenses
• Manages special projects and initiatives

Provider Reimbursement Policy Manager – Patient Safety

• Manage a team of clinicians charged with promoting quality member outcomes
• Optimize member benefits and promote effective use of resources
• Ensure adherence to medical policy and member benefits
• Authorizing outpatient services and home health services
• Apply clinical knowledge for care-coordination and manage service appeals

Manager I – Medical Management

Medical Director

• Responsible for the appeal reviews for physical health medical services
• Ensure the 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
• Supports clinicians to ensure timely and consistent responses to members and providers
• Provides guidance for clinical operational aspects of a program
• Conduct peer-to-peer clinical case reviews with attending physicians or other ordering providers
• Serves as a resource and consultant to other areas of the company
• May represent the company to external entities and/or serve on internal and/or external committees
• May chair company committees
• Interprets medical policies and clinical guidelines
• May develop and propose new medical policies based on changes in healthcare
• Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes
• Identifies and develops opportunities for innovation to increase effectiveness and quality