Elevance Health

Manager

• Responsible for managing psychiatric and substance abuse or substance abuse 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 to ensure access to medically necessary quality behavioral healthcare in a cost effective setting in accordance with UM Clinical Guidelines and contract
• Refers cases to Peer Reviewers as appropriate
• Performs psychiatric and substance abuse or substance abuse disorder assessment coordination implementation case planning monitoring and evaluating to promote quality member outcomes to optimize member health benefits and to promote effective use of health benefits and community resources
• Will serve as a resource to other BH Care Managers
• Assists with more complex cases and may participate in inter and intradepartmental teams projects and initiatives

Behavioral Health Care Manager II – Autism, BCBA, LBA

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 conditions
• Gathers history and physical exam and diagnostics as needed
• Meets the patient’s and family’s physical and psychosocial needs
• Maintains patient medical records and documentation consistent with state regulations

Nurse Practitioner, Bilingual, Virtual

IT Support

• Partner with business, IT, and delivery stakeholders to ensure implementation readiness
• Develop and manage test strategies, plans, schedules, and execution aligned to program milestones
• Coordinate onshore and offshore teams, ensuring effective communication and delivery
• Identifies potential issues, project charge, and scope
• Identifies impacted parties, business partners, and resources required
• Develops and designs processes and systems that support business needs
• Designs methods for integrating function and process
• Conducts cost/benefit analyses
• Builds support for business change throughout the business unit

Test Lead – Pharmacy Benefit Manager, PBM

QA Engineer

• Helps build and support the company's change network.
• Communicates information from a variety of sources through newsletters, dashboards and presentations.
• Promotes benefits of function within region as well as throughout the company.
• Understand the Pharmacy benefit setup & validate the configuration to ensure the accurate setup using Claims/Query testing.
• Validation of Formulary, Utilization Management & Drug List setup using Claims/Query testing.

Business Change Advisor – Test Analyst

Financial Planning and Analysis

• Lead the financial strategy and development of financial metrics for complex federal RFP submissions
• Translate RFP requirements into detailed staffing models, workload forecasts, and comprehensive cost builds
• Oversee development and validation of defensible Basis of Estimates (BOEs)
• Validate workload assumptions, staffing ratios, productivity metrics, and ramp schedules using historical data and benchmarking
• Partner with Pricing leadership to align cost builds with price-to-win strategy

Financial Accounting & Reporting Director

Account Executive

• Builds and maintains relationships with key customers of specific line of business which may include physicians, urgent care, infusion clinics, hospitals, skilled nursing centers, and payors.
• Works with leadership to develop territory sales forecasts and goals.
• Qualifies opportunities in the territory with private insurance and/or federal or state funded plans as well as potential revenue.
• Identifies and resolves customer service issues in territory.
• Assists customer service and provides necessary information to meet customer’s needs.
• Networks with industry partners.
• Partners with appropriate team members, leadership, and other principals to close deals and negotiate deliverables.
• Assesses and reports on competitive sales activities.
• Assists in the development and implementation of competitive sales strategies.
• Represents region appropriately in sales efforts.

Hemophilia Account Executive

Medical Director

• The Medical Director is responsible for the administration of physical and/or behavioral health medical services, to ensure the appropriate and most cost-effective medical care is received.
• May be responsible for developing and implementing programs to improve quality, cost, and outcomes.
• May provide clinical consultation and serve as clinical/strategic advisor to enhance clinical operations.
• May identify cost of care opportunities.
• May serve as a resource to staff including Medical Director Associates.
• Supports clinicians to ensure timely and consistent responses to members and providers.
• Provides guidance for clinical operational aspects of a program.
• Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations, and patients’ office visits with providers and external physicians.
• Interprets medical policies and clinical guidelines.
• Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes.

• Builds and maintains relationships with key customers
• Develop territory sales forecasts and goals
• Qualifies opportunities with insurance plans
• Identifies and resolves customer service issues
• Networks with industry partners

• administration of physical and/or behavioral health medical services
• developing and implementing programs to improve quality, cost, and outcomes
• clinical consultation and advisory roles
• support for clinicians to ensure timely responses to members and providers

Medical Director – Family Medicine

Product Manager

• The Agile Product Manager is responsible for representing the needs of the stakeholder community to the team of Agile teams
• Accountable for one or more Agile teams and drives the solution concept across these multiple teams
• Understand customer needs and participates in validation of proposed solutions
• Collaborates to continuously develop and communicate the vision for the scrum teams
• Manages the program Epic/Initiative backlog at the Agile Lean Program Level
• Partners with stakeholders to develop the business case for Epics/features
• Utilizes key performance indicators (KPIs) to measure product performance
• Advocates for current and future funding
• Supports portfolio work including budget parameters
• Collaborates with the system and solution architects
• Builds effective product manager/product owner team for multiple trains
• Drives business value delivery at the program level
• Designs and runs evaluations to assess product performance
• Manages backlog management, sprint planning, and writes clear user stories

Agile Product Manager – Growth Execution

Consultant

• Provide the highest level of analytical support to the Cost of Care and/or Provider Contracting organizations
• Lead efforts to support regulatory reporting requirements for government entities and regulatory bodies
• Gather, consolidate, analyze, and submit data to ensure compliance with healthcare expenditure regulations
• Serve as a subject matter expert for regulatory reporting
• Collaborate with various teams to gather and interpret requirements
• Retrieve, consolidate, and collate data from multiple data warehouses to produce comprehensive reports
• Develop complex reporting applications and strategic data solutions
• Undertake complex assignments requiring specialized technical knowledge
• Establish and communicate common goals and directions for team
• Monitor project schedules and costs for own and other projects
• Conduct training on use of applications developed

Senior Provider Contract/CofC Consultant

People Operations

• Manage and balance sprint work to align with complexity, risk, and strategic priorities while maintaining quality and scalability
• Guide enterprise demand for People Enablement services, translating business priorities into actionable work and ensuring efficient prioritization
• Manage enablement work from inception to delivery, establishing clear scopes and removing obstacles to sustain progress
• Act as a communication hub, providing ongoing updates on project status and risks, and ensuring cohesive messaging across HR roles
• Ensure effective adoption of solutions and capture lessons learned to refine future initiatives
• Hires, trains, coaches, counsels, and evaluates performance of direct reports

Director, People Enablement

• manage a team of clinicians charged with promoting quality member outcomes
• optimize member benefits
• promote effective use of resources
• ensures adherence to medical policy and member benefits in providing medically appropriate service
• authorizing inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services
• appropriateness of treatment setting by utilizing applicable medical policy and industry standards
• steering members to appropriate providers, programs or community resources
• applies clinical knowledge to work with facilities and providers for care-coordination
• managing appeals for services denied
• hiring, training, coaching, counseling, and evaluating performance of direct reports

Manager I – Medical Management

• Responsible for leading the quality documentation, coding and value capture for all provider visit medical encounters to ensure application of accurate diagnosis codes (ICD-10 codes)
• Serves as the primary resource and subject matter expert on all CMS Risk Adjustment and quality documentation
• Develop and deliver training on advance coding and documentation while incorporating coder feedback
• Lead the coding department and coding initiatives
• Liaison to the clinical leadership on alignment of goals and workflows to support value capture initiatives and high-quality clinical documentation
• Develop performance management plan, KPI's and clinical level tracking to meet quarterly goals for coding timeliness, accuracy, and Risk Adjustment
• Develop and manage clinical quality reviews to ensure peer review and clinical quality chart audit process including targeting chart reviews, auditing percentages, score guidelines feedback mechanism and ensure compliance with remediation procedures
• Develop operational and clinical workflows for closing HEDIS care opportunities to ensure practices and health plan success
• Participate in peer review of medical documentation for completed visits notes as well as patient profile information in EMR
• Hires, trains, coaches, counsels, and evaluates performance of direct reports

Manager, Clinical Performance and Quality Coding

• Responsible for ensuring effective psychosocial intervention
• Manages behavioral and psychosocial needs
• Assists members to effectively utilize available resources
• Evaluates members' ability to independently manage self
• Provides guidance to members seeking alternative solutions
• Evaluates members' strengths related to health self-management
• Facilitates and coordinates behavioral health resources as individual member needs are identified

Behavioral Health Care Manager II – Autism, BCBA, LBA

Nurse Practitioner, Bilingual, Virtual

Test Lead – Pharmacy Benefit Manager, PBM

Business Change Advisor – Test Analyst

Financial Accounting & Reporting Director

Hemophilia Account Executive

Medical Director

Hemophilia Account Executive

Medical Director – Family Medicine

Agile Product Manager – Growth Execution

Senior Provider Contract/CofC Consultant

Director, People Enablement

Manager I – Medical Management

Manager, Clinical Performance and Quality Coding

Social Work Case Manager