Elevance Health

Growth Marketing

• Develops and implements client retention and account growth strategies
• Ensures client deliverables and contractual obligations are consistently met
• Provides strategic direction and coaching to Client Partnership Directors
• Partners with leadership to identify market trends and translates insights into actionable strategies
• Supports system implementations and migrations
• Leads, mentors, and develops a team fostering a high-performance culture
• Drives consistency in client management practices

Director – Client Management, Carelon Services

Manager

• Managing psychiatric and substance abuse or substance abuse disorder facility-based and outpatient professional treatment health benefits
• Using appropriate screening criteria knowledge and clinical judgment to assess member needs
• Referring cases to Peer Reviewers as appropriate
• Assisting with more complex cases and may participate in inter and intradepartmental teams projects and initiatives

Behavioral Health Care Manager II

General Counsel

• Primarily responsible for managing defensive, and where appropriate, affirmative litigation for health plans
• Includes internal fact investigation, strategic decision-making and partnering with business and outside counsel
• Providing risk assessment and guidance to various business areas on a wide variety of issues
• Providing litigation support to our behavioral health, PBM, specialty pharmacies, benefits management company and overpayment investigation and recovery areas
• Works as a strategic partner and decision maker with more senior leaders
• Manages work independently

Associate General Counsel – Litigation

Risk

• Set and execute the enterprise strategy for commercial risk adjustment
• Own program performance, operating model design, regulatory and audit readiness
• Partner closely with enterprise functions and leaders to deliver measurable improvements
• Define and lead the multi-year commercial risk adjustment strategy, roadmap, and annual operating plan
• Establish a scalable operating model with clear accountability and performance management
• Build, mentor, and lead high-performing teams across risk adjustment operations
• Serve as the executive point of accountability for commercial risk adjustment performance
• Own end-to-end performance across risk capture, coding accuracy, documentation improvement
• Lead provider-facing risk adjustment enablement strategy including education and workflow integration
• Sponsor analytics and technology capabilities to support risk adjustment
• Ensure compliant, ethical risk adjustment practices

Staff VP, Commercial Risk Adjustment

• Develops, implements and controls the credentialing process for all in-house professional provider consultants and all contracted providers within the region
• Provides guidance regarding policies, procedures and regulatory requirements
• Ensures that all legal, licensure and accreditation standards are met
• Reviews the approval and termination of professional provider contracts as they relate to the credentialing process
• Ensures the accurate and timely information for the purposes of re-credentialing, data analysis and directory generation as well as recommending changes to the credentialing criteria and processes
• Monitors all governmental and private agency initiatives in the credentialing area
• Ensures all credentialing and re-credentialing policies and processes are in compliance with NCQA and all applicable state regulations
• Assures credentialing activities are integrated within the appropriate QI committees and departments
• Hires, trains, coaches, counsels and evaluates performance of direct reports

Manager II, Credentialing – BioPlus Specialty Pharmacy

Solutions Engineer

• Maintain active relationships with business stakeholders to understand needs, gather requirements, and review solution designs
• Facilitate large group JAD sessions as needed
• Submit initiative intake requests and owns review of Level of Effort (LOE) estimates
• Engage Enterprise IT teams to validate feasibility, standards, and dependencies
• Define application scope and objectives
• Supervise preparation of functional and/or technical specifications
• Maintain technical decision logs and ensure traceability from requirements through design, build, testing, and release artifacts
• Own the change request process, coordinate cross-team delivery, and develop/maintain the prioritized list of approved enhancements
• Lead delivery of application enhancements and projects
• Perform/coordinate technical design reviews and code reviews
• Ensure appropriate testing is completed (unit, system/integration, regression, performance as applicable) and the solution is implemented according to plan
• Validate non-functional requirements (performance, scalability, security, monitoring, supportability) are defined and addressed prior to implementation
• Drive train-level and team/Scrum-level risk and dependency management; escalate issues and propose mitigation options
• Coordinate technical readiness and obtain required release approvals
• Coordinate and manage production support
• Own the system monitoring process
• Lead root cause analysis and corrective/preventive actions
• Monitor the spend against the budget for the portfolio/initiatives and flag variances and risks early
• Lead vendor evaluation and analysis
• Manage vendor delivery performance as applicable
• Contribute to application technology solution delivery and data/information planning efforts

Senior Solutions Engineer

Financial Planning and Analysis

• Reviews and validates paid claims for overpayments using various techniques
• Determines and calculates amount of overpayments and processes refunds
• Researches voluntary refunds for accuracy
• Requires accurate balancing of all accounts
• Responsible for more routine issues
• May work with internal staff from other departments to ensure customer satisfaction
• May perform collection activities to ensure the recovery of overpayments

Financial Operations Recovery Specialist I

• Responsible for performing case management telephonically and/or by home visits for behavioral health and substance abuse needs
• Uses appropriate screening criteria and clinical judgment to assess member needs
• Conducts assessments to identify individual needs and develops care plans
• Monitors and evaluates effectiveness of care plans and modifies as needed
• Coordinates with internal and external resources to meet identified needs of the members and collaborates with providers

Behavioral Health Case Manager I – Pediatric and Adult Care Coordination

• Conducts assessments to identify individual needs
• Develops comprehensive care plan to address objectives and goals as identified during assessment
• Supports member access to appropriate quality and cost-effective care and modifies plan(s) as needed
• Coordinates with internal and external resources to meet identified needs of the member in terms of integrated (physical and behavioral) whole person care
• Coordinates social determinants of health to meet the needs of the member and incorporates that into care planning
• Works closely with various state agencies
• Maintains knowledge of the system of care philosophy; a spectrum of effective, community-based services and supports for those with or at risk for mental health or other challenges and their families, that is organized into a coordinated network
• Builds meaningful partnerships with designated populations and their families, and addresses cultural and linguistic needs, in order to help them function better at home, in the community, and throughout life
• Evaluates health needs and identifies applicable services and resources in conjunction with members and their families
• Provides important information including patient education, medication reconciliation, and identification of community resources and assists with arrangement of follow-up care

Special Programs Case Manager I – Licensed

Consultant

• Calculates renewal rates for large complex cases based on thorough analysis of experience data, location, demographics, etc.
• Provides guidance to the actuarial team for administrative service costs associated with risk opportunities.
• Coordinates with other departments to ensure accuracy on resource allocation and consistency of overall account reporting.
• Proposes various rate structures for prospective business utilizing a combination of other carrier experience, demographic data and manual rates.
• Facilitates and documents deal approval process
• Performs post-sale reviews.
• Prepares or supervises preparation of annual settlements, ERISA reports, rate projections, or benefit change increments and decrements.
• Surveys existing product portfolios by market, monitors sales results, trends and needs, recommends product portfolio changes.
• Assists in establishing rating and administrative procedures.
• Participates in major multi-functional teams as underwriting representative.
• Assists in the technical development of underwriting associates.
• Updates and monitors departmental processes and procedures in compliance with system, regulatory and business requirements.

Senior Group U/W Consultant

Actuary

• Completes diverse and complicated projects and performs highly complex actuarial studies
• Performs key actuarial functions including new product pricing and evaluation of the impact of new legislation
• Designs and completes special projects such as developing and maintaining experience-rating formulae
• Responsible for recommendations on pricing, marketing, product design, claims, premium and enrollment administration of business unit
• Provides valuation support for business unit by interpreting financial results

Associate Actuary

• Supports Employee Assistance Program (EAP) service department by responding to initial customer contacts and request for services
• Receives client request, assesses situation, determines appropriate course of action
• Provides telephone and or on-site support for crisis intervention, assessment, short term problem resolution and referral to appropriate provider(s)
• Manages Critical Incident Stress Debriefing requests
• Assesses members and assists them in accessing behavioral healthcare benefits available under their health plan
• Manages shared mailbox that is used by clients and external vendor to forward information that must be reviewed and placed in documentation system

Behavioral Health EAP Consultant I

Medical Director

• Oversee the administration of behavioral health services
• Provide clinical consultation and strategic guidance
• Ensure timely and consistent responses to members and providers
• Conduct peer-to-peer clinical reviews
• Serve as a resource and consultant to other areas of the company

Behavioral Health Medical Director – Psychiatrist

Underwriter

• Calculates renewal rates for large complex cases based on thorough analysis of experience, location, demographics, etc.
• Determines and provides guidance to medical underwriters concerning the risk selection of applicants applying for individual 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.
• Surveys existing product portfolios by market, monitors sales results, trends and needs, recommends product portfolio changes.
• Assists in establishing rating and administrative procedures.
• Participates in major multi-functional teams as underwriting representative.
• Assists in the technical development of underwriting associates, which may include monitoring reports and workflow to provide recommendations on productivity and efficiency improvements.
• Updates and monitors departmental processes and procedures in compliance with system, regulatory and business requirements.

Stop Loss Group Underwriting Consultant

Bilingual

• Responsible for new and existing patients
• Outreach to patients, explaining the benefits of programs, and guiding them through the enrollment process
• Reviewing and prioritizing patient census
• Reaching out to patients to explain services and enrolling them into the appropriate programs
• Coordinate with internal teams to ensure seamless patient onboarding
• Meet or exceed enrollment targets and key performance indicators
• Providing support by addressing inquiries and scheduling initial and annual appointments
• Enters documentation into designated systems