Elevance Health

Auditor

• Examines claims for compliance with relevant billing and processing guidelines
• Identifies opportunities for fraud and abuse prevention and control
• Reviews and conducts analysis of claims and medical records prior to payment
• Uses required systems/tools to accurately document determinations
• Researches new healthcare related questions as necessary to aid in investigations
• 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
• Assists with training of new associates

Clinical Provider Auditor II

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
• Performing psychiatric and substance abuse or substance abuse disorder assessment coordination, implementation, case planning, monitoring, and evaluating to promote quality member outcomes
• Serving as a resource to other BH Care Managers

Behavioral Health Care Manager II – Autism

• Conducting service coordination functions for a defined caseload of individuals in specialized programs
• Facilitates the Person Centered Planning process
• Conducts assessments and develops comprehensive Person Centered Support Plans
• Manages individuals’ physical health, behavioral health, and LTSS needs
• Documents service and support goals in collaboration with care teams
• Submits utilization/authorization requests to management
• Responsible for reporting critical incidents and assisting in appeals or grievances

LTSS Service Coordinator – Case Manager

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

• Perform care management within scope of licensure 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 and care management plan

Nurse Case Manager

Consultant

• Responsible for quality documentation, coding and value capture
• Supply clinical expertise to ensure full accurate and appropriate diagnosis, documentation, coding and care
• Review all provider visit medical encounters and apply most appropriate diagnosis codes
• Accountability for the HCC/Risk Adjustment of goals and workflows to support value capture initiatives
• Liaison to coding team
• Chart reviews for closing HEDIS care opportunities
• Participate in peer review of medical documentation for completed visit notes and patient profile information in EMR
• Review and correct any ICD-10 codes assigned in charts
• Provide feedback to the provider for improved documentation

Clinical Quality Consultant

• Oversees and manages Clinical Programs operations.
• Manages patient caseloads.
• Provides resources and direction to Nurse Practitioners.
• Performs physical examinations, preventive health measures, and follow up visits within prescribed guidelines and physician instructions.
• Orders, interprets and evaluates diagnostic tests to identify and assess patient's clinical problems and health care needs.
• Discusses case with physician and formulates and documents care plan.
• Prescribes medication or other forms of treatment.
• Reviews documentation to ensure compliance with best practices, protocols, and quality measures.
• Hires, trains, coaches, counsels, and evaluates performance of direct reports.

Manager, Nurse Practitioners

Financial Planning and Analysis

• Responsible for all month-close functions, including reviewing and approving journal entries, reconciliations, and related reporting.
• May lead teams of associates.
• Reviews and approves complex accounting and financial analysis based on trend, plan and forecast.
• Lead various committees or work groups to develop, implement, modify, and document new or revised accounting processes, procedures, systems and tracking mechanisms.
• Ensures requirements of Sarbanes-Oxley are being met.
• Works on extremely complex problems/issues where analysis of situations or data requires an evaluation of intangible factors, innovative solutions, and effective and collaborative leadership.
• Mentors, trains, and coaches lower-level accountants.

Financial Accounting Analyst, Manager

Account Executive

• Partners with leadership to identify sales opportunities
• Understands all aspects of the business and partners with executive leadership to define strategy
• Establishes, builds, and nurtures executive level relationships at targeted accounts
• Articulates and introduces specific solutions to new customers
• Establishes and maintains a high level of visibility within industry groups
• Translates strategy into defined tactics, programs/projects priorities, and timelines
• Collaborates with and influences product development strategies
• Identifies, pursues, and closes net new opportunities and accounts
• Develops strategies and executes sales plans to achieve membership growth and financial goals

Sales Executive – Behavioral Health

• Conduct service coordination functions for a defined caseload
• Perform face to face program assessments for identification
• Manage non-clinical needs of members with chronic illnesses
• Document the member’s service and support goals in collaboration with the member’s care team
• Submit utilization/authorization requests with documentation supporting care plans
• Report critical incidents to appropriate parties

Medical Director

• Provides clinical guidance for pharmacy prior authorizations
• Conducts peer-to-peer prior authorization reviews with physicians
• Supports timely responses to members and providers
• Participates in a physician on-call weekend rotation

Medical Director Associate

• Responsible for conducting service coordination functions for a defined caseload of individuals in specialized programs
• Facilitates the Person Centered Planning process
• Conducting assessments, development of comprehensive Person Centered Support Plan (PCSP) and backup plan
• Engaging the member’s circle of support and overall management of the individuals physical health (PH)/behavioral health (BH)/LTSS needs
• Responsible for performing face to face program assessments
• Uses tools and pre-defined identification process
• Coordinates those member’s cases with the clinical healthcare management and interdisciplinary team
• Responsible for reporting critical incidents to appropriate internal and external parties such as state and county agencies
• Assists and participates in appeal or fair hearings, member grievances, appeals, and state audits

• Manages the lifecycle of payor contracts including review, interpretation, implementation, amendments, and renewals
• Serves as subject matter expert on contract terms including reimbursement methodologies, fee schedules, carve-outs, drug-level pricing, site-of-care requirements, and network participation
• Tracks contract expirations, renewals, and amendments to ensure uninterrupted access and compliance
• Analyzes reimbursement methodologies (AWP, WAC, ASP, MAC, per diem, case rates, nursing fees, supplies, admin fees) and identifies reimbursement risks, underpayments, and revenue leakage
• Partners with finance and revenue cycle to resolve reimbursement discrepancies and payment disputes and supports forecasting, margin analysis, and payor profitability reporting
• Translates contract terms into operational requirements for pharmacy systems, billing platforms, and claim adjudication logic and coordinates with IT and pharmacy operations to ensure accurate setup of pricing and payor-specific rules
• Supports payor mapping tied to BIN/PCN, NCPDP, NPI, and taxonomy configurations
• Ensures contracts comply with federal and state regulations including CMS, Medicare Part B and D, Medicaid, 340B, and anti-kickback requirements; maintains audit-ready documentation; and supports internal/external audits
• Acts as the primary contract resource for internal teams; provides contract education to support accurate billing and payor compliance; and supports payor escalations, access issues, and network participation inquiries

Payor Contract Manager, Specialty Pharmacy

• Manages the lifecycle of payor contracts including review, interpretation, implementation, amendments, and renewals.
• Serves as subject matter expert on contract terms including reimbursement methodologies, fee schedules, carve-outs, drug-level pricing, site-of-care requirements, and network participation.
• Tracks contract expirations, renewals, and amendments to ensure uninterrupted access and compliance.
• Analyzes reimbursement methodologies (AWP, WAC, ASP, MAC, per diem, case rates, nursing fees, supplies, admin fees) and identifies reimbursement risks, underpayments, and revenue leakage.
• Partners with finance and revenue cycle to resolve reimbursement discrepancies and payment disputes and supports forecasting, margin analysis, and payor profitability reporting.
• Translates contract terms into operational requirements for pharmacy systems, billing platforms, and claim adjudication logic and coordinates with IT and pharmacy operations to ensure accurate setup of pricing and payor-specific rules (including NDC requirements, J-codes, modifiers, and site-of-care billing logic).
• Supports payor mapping tied to BIN/PCN, NCPDP, NPI, and taxonomy configurations.
• Ensures contracts comply with federal and state regulations including CMS, Medicare Part B and D, Medicaid, 340B, and anti-kickback requirements; maintains audit-ready documentation; and supports internal/external audits.
• Acts as the primary contract resource for internal teams; provides contract education to support accurate billing and payor compliance; and supports payor escalations, access issues, and network participation inquiries.

Payor Contract Manager, Infusion

Ecommerce

• Responsible to create and drive enterprise self-service, digital product and experience and personalization strategy
• Develop business case and enterprise alignment and sign-off on value of key digital and conversational AI experience investments
• Leads implementation and execution of an AI-enabled self-service roadmap for the company
• Responsible for omni-channel product prioritization to achieve consumer engagement and experience objectives
• Liaison with key stakeholders and business leaders for digital experience priorities
• Hires, trains, coaches, counsels, and evaluates performance of direct reports

Clinical Provider Auditor II

Behavioral Health Care Manager II – Autism

LTSS Service Coordinator – Case Manager

Sales Support Coordinator I

Nurse Case Manager

Clinical Quality Consultant

Manager, Nurse Practitioners

Financial Accounting Analyst, Manager

Sales Executive – Behavioral Health

LTSS Service Coordinator – Case Manager

Medical Director Associate

LTSS Service Coordinator – Case Manager

Payor Contract Manager, Specialty Pharmacy

Payor Contract Manager, Infusion

Staff VP, Digital Experience and Engagement