Elevance Health

Customer Support

• Responds to 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
• 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
• Researches and analyzes data to address operational challenges and customer service issues
• Provides external and internal customers with requested information
• Under immediate supervision, 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
• Requires limited knowledge of company services, products, insurance benefits, provider contracts and claims
• Seeks, understands and responds to the needs and expectations of internal and external customers

Customer Care Representative – Bilingual, English/Spanish

Director

• Oversees Inventory Management, Demand Forecasting, and Data Analysis.
• Leads a team of business analysts and managers accountable for supporting inventory management, claims forecasting, and staffing activities.
• Develops long-range workforce planning models and forecasts accounting for.
• Oversees project and process improvement work for claims operations.
• Significantly impacts the company’s ability to maintain and improve claims inventory aging and processing timeliness goals while improving administrative cost structure.
• Works closely with other claims operations directors to achieve shared goals.
• Performs data analysis and develops new metrics and key performance indicators to improve performance.
• Utilizes and advises on digital tools and technology to improve claims performance.
• Demonstrates strong people-management skills with the ability to mentor, coach, and develop a team of associates.
• Travels to worksite and other locations as necessary.

Director, Workforce Management

Program Manager

• Direct the development, planning, prioritization, approval, implementation, and governance of enterprise Voice of the Customer and Consumer Effort programs, ensuring timely response to issue escalation and alignment to stated objectives.
• Lead the enterprise Consumer Effort Command Center, including hotspot reviews, root-cause discussions, owner follow-up, action tracking, and executive updates.
• Manage VoC intake, prioritization, roadmap, backlog, decision log, risk register, and benefits tracking to translate high-impact member pain points into clear action plans and measurable outcomes.
• Partner with Analytics, Digital, Operations, Product, Clinical, Pharmacy, Provider, Technology, Compliance, and corporate and regional business teams to connect VoC insights to operational drivers and coordinate resources across multiple departments.
• Provide subject matter expertise on day-to-day business issues, research relevant practices, and stay current on industry trends and emerging AI-enabled capabilities that can improve member experience.
• Use AI-enabled tools for topic discovery, sentiment analysis, verbatim summarization, anomaly detection, journey diagnostics, and executive storytelling, while ensuring outputs are human-reviewed, explainable, and appropriate for a regulated healthcare environment.
• Facilitate cross-functional action sprints and develop communication materials, training criteria, presentations, and program reporting tied to success measures and pre/post impact.
• Identify opportunities where virtual assistants, agent assist, self-service, knowledge management, proactive outreach, or agentic AI can reduce member effort and improve service outcomes.
• Manage leadership communications and executive-ready updates that distinguish true experience signals from noise, volume mix, or data-quality issues.
• Provide leadership to program managers and project managers, while maintaining strong partnerships with external-facing stakeholders and senior executives.

Program Director, Voice of the Customer – Insights

Manager

• Provides strategic planning and account management for large accounts.
• Directs and manages the administration of contractual requirements and obligations.
• Manages the new and renewal implementation process for accounts.
• Interfaces with operations to ensure smooth delivery of services.
• Maintains ongoing account relationships at multiple levels throughout the customer's organization.
• Makes recommendations for improvements to meet customer's expectations.
• Develops implementation processes and manages reporting processes to ensure client retention and high levels of account satisfaction.
• Provides both on-site and off-site account management, which may include interpreting plan design, researching and resolving phone and written inquiries, resolving claims, benefit and enrollment issues.
• Presents monthly, ad hoc, mid-year, and annual utilization and benefit reporting to the broker and client.
• Coordinates open enrollment meetings, renewal process and training sessions.
• Participates in efforts to support standardization across accounts and works in multi-disciplinary teams to design and implement product and operational enhancements.
• Provides guidance or expertise to less experienced account service managers.
• Makes routine account visits.

Senior Account Service Manager

Consultant

• Calculates renewal rates for large complex cases
• Provides guidance to the actuarial team
• Coordinates with other departments for accuracy
• Proposes rate structures for prospective business
• Facilitates and documents deal approval process
• Prepares annual settlements and reports
• Surveys existing product portfolios and monitors sales results
• Assists in establishing rating and administrative procedures
• Participates in multi-functional teams as underwriting representative
• Assists in technical development of underwriting associates
• Updates departmental processes in compliance with requirements

Senior Group Underwriter Consultant

Call Center Representative

• Provides evaluation of member Rx needs and therapies through review of medication history
• Assesses member compliance with plan through direct contact with members and their physicians
• Determines potential barriers to compliance and identifies solutions to overcome barriers
• Ensures that members understand appropriate use of current prescriptions
• Reviews medications with physicians when therapies do not meet national standards and counsels physicians around alternative medications
• Serves as a resource to the clinical team in disease management and other clinical areas

Pharmacist Consultant – CarelonRx Call Center

• Verifies member information and inputs data for the pharmacists
• Educates members about prescriptions and medication resources or assistance programs
• Educates members on medication adherence-related topics to align closely with STARs Ratings and HEDIS quality measures
• Assists members with scheduling their preventive tests/screenings and medication resources or assistance programs
• Makes outreach to members or providers to close care gaps and improve outcomes

Pharmacy Tech II – CarelonRx Call Center

Software Engineer

• Develops in-depth analytical reports
• Provides support for Level I & II analysts
• Designs formats for data studies and analyses
• Works with internal customers to determine additional metrics needed
• Designs complex systems, databases and reports to analyze and evaluate data from multiple repositories
• Works with Advisors to review and interpret data results
• Develops written narratives, table charts and graphs to display data

Metrics Advisor, SQL Developer

• Work with management to identify and implement projects, programs and plans to support business goals
• Support Carelon payment integrity
• Identify potential issues, project charge, and scope
• Lead efforts to identify best practices
• Identify impacted parties, business partners, and resources required
• Develop and design processes and systems that support business needs
• Conduct cost/benefit analyses
• Build support for business change throughout the business unit

Business Change Manager

• Sets the strategic direction for audit methodologies
• Oversees team development
• Ensures that audits meet the industry’s best practices and payer-specific requirements
• Collaborates cross-functionally with clinical, compliance, provider engagement, and data analytics teams to align audit insights with broader program goals
• Hires, trains, coaches, counsels, and evaluates performance of direct reports
• Analysis of audit trends, DRG shifts
• Plans program/project scope and design
• Develops metrics and program/project reporting tools
• Analyzes variance to program/project plan
• Leads building of documentation to support business objectives and ensure consistency
• Suggests and develops high quality, high value concept and or process improvement and efficiency recommendations
• Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions.

Manager, DRG Coding – Clinical Validation Audit

Account Executive

• Developing and maintaining relationships with external clients and prospects
• Reaching internal health plan penetration goals through consultative skills
• Supporting the strategic sales and tactical plans by consulting with key decision makers
• Providing ongoing support to regional decision makers and support pharmacy benefit management (PBM) field sales team during RFP processes
• Assisting in the development of recommendations for outcomes-based savings and revenue opportunities

Pharmacy Account Executive

Auditor

• Auditing inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed
• Analyzing and auditing claims by integrating medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities
• Utilizing audit tools, auditing workflow systems and reference information to generate audit determinations and formulate detailed audit findings letters
• Maintaining accuracy and quality standards as established by audit management
• Identifying potential documentation and coding errors by recognizing aberrant coding and documentation patterns
• Suggesting and developing high quality, high value, concept and or process improvement and efficiency recommendations

Clinical Validation Auditor – RN, CDI, MS-DRG, AP-DRG, APR-DRG

• 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, edits, behavioral health standards, billing, and coding conventions
• 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 Manager – Behavioral Health, Coding

Medical Director

• Determines the medical necessity of requests using clinical criteria
• Performs physician-level case review of surgical utilization requests
• Conducts peer-to-peer consultation with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, procedures, imaging and appropriate sites of service
• Provides education regarding applicable clinical criteria and discusses clinically appropriate interventional and non-interventional options
• Performs first level provider appeals for coverage decisions
• Provides support and education to internal clinical and non-clinical staff regarding the principles associated with appropriate diagnoses, treatments, and management of conditions and surgical procedures
• Participates in physician team meetings
• Participates in groups that develop, revise and enhance clinical appropriateness guidelines

Medical Director – Surgery

• Leads planning and implementation of Cardiovascular and Radiology Benefits Management solutions
• Serves as the single point of contact and subject matter expert on all aspects of planning, implementing and managing day-to-day operational, technical and business partner interactions for existing programs
• Works together with Product Development to consult on enhancements to existing products and development of new clinical solutions based on analytics
• Provides consultation and advice to business partners regarding benefits of products and analytics
• Explains timelines and measures of success for implementing these products
• Coordinates with the Physician Liaison regarding clinical issues related to clinical measure implementation or customization by line of business
• Communicates changes to Product Development for consideration in product performance and financial analyses
• Schedules and coordinates implementation of contracted products and services for assigned business partners
• Coordinates data requirements, production schedules and deliverables with the business partner
• Oversees all business partner specifications and/or modifications for contracted products and services
• Provides business partners with the resources, training and services necessary to effectively utilize the products that the department provides
• Analyzes business partner data for QA and identification of opportunities for business partners to utilize products and services to improve plan performance
• Maintains detailed knowledge of current clinical measures and future clinical measure development plans
• Communicates information to business partners, assisting in selection of clinical measures to be utilized in pilot and full rollout of products and services
• Guides business partners in continually reviewing and updating clinical measure sets
• Maintains detailed knowledge of all current systems, products and services and basic understanding of future system and product development plans to allow appropriate level of communication with business partner
• Leads department projects and mentors’ solutions management staff