Elevance Health

Consultant

• 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
• Ensures that members understand appropriate use of current prescriptions
• Reviews medications with physicians when therapies do not meet national standards
• Serves as a resource to the clinical team in disease management and other clinical areas

Pharmacist Consultant

Medical Director

• Determines the medical necessity of requests using clinical criteria
• Performs physician-level case review of musculoskeletal 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, surgical procedures, imaging and appropriate sites of service
• Provides education regarding applicable clinical criteria and discusses clinically appropriate alternative surgical and non-surgical treatments
• Performs first level provider appeals of coverage decisions
• Provides support and education to internal clinical and non-clinical staff regarding the principles associated with appropriate musculoskeletal diagnoses, treatments, and management
• Participates in physician team meetings
• Participates in groups that develop, revise and enhance clinical appropriateness guidelines

Associate Medical Director – Orthopedic Spine Surgery

Compliance

• Manage/oversee projects, initiatives, regulatory audits or exams, internal audits, accreditations, on-site reviews, risk assessments
• Audit planning, conducting mock audits, conducting audit training, managing audit evidence preparation, assessing audit preparedness
• Establish project plans, gap analysis, milestone dates, and other significant aspects, and leadership updates
• Maintain knowledge of laws, regulations, company strategies to assess impact, and consult with clients as a subject matter expert
• Conduct complex investigations, document findings, and ensure corrective actions are made
• Interface with external clients, regulators, vendors, suppliers, internal stakeholders and high level of management

Compliance Manager

Actuary

• Analyzes and implements risk contracts including conducting experience analyses, pricing, filing and settlement work; and prepares management reports supporting new capitation initiatives.
• Assists in training of actuarial trainees, analysts and specialists.
• Coordinates/directs special actuarial projects.

Actuarial Analyst III

• Analyzes and implements risk contracts
• conducting experience analyses
• pricing, filing and settlement work
• prepares management reports supporting new capitation initiatives
• Assists in training of actuarial trainees, analysts and specialists
• Coordinates/directs special actuarial projects

Manager

• This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy.
• Ensures member access to services appropriate to their health needs.
• Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.
• Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.
• Coordinates internal and external resources to meet identified needs.
• Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
• Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.
• Negotiates rates of reimbursement, as applicable.
• Assists in problem solving with providers, claims or service issues.
• Assists with development of utilization/care management policies and procedures.

Nurse Case Manager II

Therapist

• Provide guidance to condition management members for positive lifestyle changes
• Collaborate with health professionals to improve member health
• Provide instructions on inhalers, breathing techniques, and prevention techniques
• Coach members on health changes focusing on Asthma and COPD

Respiratory Therapist

Director

• Specializes in and directly supports Epic Payer Platform integration initiatives
• Identifies potential issues, project changes, and scope data
• Leads efforts to identify best practices in process improvement
• Identifies impacted parties, business partners, and resources required
• Develops and designs processes and systems that support business needs
• Designs methods for integrating functions and processes
• Conducts cost/benefit analyses for integration enhancements
• Builds support for business change throughout the business unit
• Provides process, project, and change management methodology coaching
• Leads project prioritization and scheduling activities
• Provides expertise to business areas in culture/change management activities
• Supports the execution of the operating plan
• Actively participates in Epic Payer Platform governance and cross-functional meetings

Business Change Director

Analyst

• researching and documenting complex projects and work processes
• ensuring business continuity and consistency
• performing research, extrapolating, compiling and validating data on flows, systems, coding, and testing problems
• making recommendations for process changes
• working with management to obtain sign-off and to implement changes
• developing and updating flows and end-user documentation based on research and system changes
• facilitating issues meetings

Senior Documentation Analyst

Billing Specialist

• improvement of lives and communities
• making healthcare simpler
• a hybrid workforce strategy
• specific requirements for onsite work will be discussed during the hiring process

Senior Billing Specialist, Pharmacy

Software Engineer

• Works to develop knowledge of enterprise technology tools, resources, processes and systems.
• Works to develop relationships with the internal or external stakeholders to understand business and technical requirements.
• Will learn end to end IT engineering and change request process.
• Creates exhibits and other support materials as necessary.
• Assists with documenting less complex business and technical requirements for coding on system components.
• Assists in developing unit test plans while given specific tasks to support implementation.
• Works on developing testing best practices.
• Assists with providing on-call support and monitoring systems as needed.
• May assist in facilitating small groups on peer code reviews.
• May participate in vendor evaluations.

Application Developer – Engineer I

Operations

• Conduct regulatory research related to state licensing, reporting, and compliance requirements
• Update and maintain regulatory reference materials and tracking documents
• Analyze regulatory changes and summarize key impacts for internal stakeholders
• Assist in developing new research memoranda on emerging regulatory topics
• Support documentation, tracking, and organization of compliance materials
• Collaborate with cross-functional partners to gather information and clarify regulatory requirements
• Present research findings in clear, concise written summaries

Operations Intern

Customer Support

• Completes administrative duties for efficient operations
• Notifies physician offices of the outcome of patient benefit investigations
• Triages prescriptions to in-network pharmacy if unable to be filled through internal channels
• Assists physician offices with prior authorization submissions and follows up with health plans and/or physician offices to obtain authorization
• Works with mandated in-network pharmacies to obtain order status
• Follows all brand drug specific program steps and documents
• Supports all activities in the delivery of medications such as assisting the center in obtaining missing documentation and communicating information to physician offices
• Maintains client relationship management (CRM) and electronic medical records (EMR) and other documentation
• Answers and routes phone calls for sales staff

Sales Support Specialist – BioPlus Specialty Pharmacy

Account Executive

• Responsible for achieving client retention by identifying client strategy and developing deep familiarity with all aspects of client contracts including products, service levels, and client KPIs.
• Foster collaboration with key stakeholders to develop account plans for each client and achieve shared goals.
• Identify and execute cross-sell / upsell opportunities to achieve gross margin, P&L and EBITDA targets.
• Understands and leverages data on account performance and provides input on the regional growth strategy each year.
• Takes a lead role in client meetings, upsells and RFPs / Rebids.
• Serves as a key client contact for independent resolution and innovation for client executive teams.
• Coaches Account Managers as needed.
• Lead and influence communications with C-suite leadership on company value proposition and alignment to client strategy.
• Manage client expectations and negotiates mutually beneficial contract terms and deliverables with client team.
• Champions change initiatives and tailors style to meet client expectations.

Account Executive III

Bilingual

• Provides primary and urgent health care via telephone and tele video modalities to patients who receive home and community-based services through state Medicaid programs, dual eligible members and other membership as assigned by our MCO partners.
• Develops and implements clinical plans of care for adult patients facing chronic and complex conditions (e.g., co-morbid medical and mental health diagnoses, limited personal resources, chronic medical conditions.)
• Gathers history and physical exam and diagnostics as needed, and then develops and implements treatment plans given the patient’s goals of care and current conditions.
• Identifies and closes gaps in care.
• Meets the patient’s and family’s physical and psychosocial needs with support and input from the company’s inter-disciplinary team.
• Educates patients and families about medication usage, side effects, illness progression, diet and nutrition, medical adherence and crisis anticipation and prevention.
• Maintains contact with other clinical team members, patients’ other physicians and patients’ other medical providers to coordinate optimal care and resources for the patient and his or her family in a timely basis and consistent with state regulations and company health standards and policy.
• Maintains patient medical records and medical documentation consistent with state regulations and company standards and policy.
• Participates in continuing education as required by state and certifying body.
• Prescribes medication as permitted by state prescribing authority.

Pharmacist Consultant

Associate Medical Director – Orthopedic Spine Surgery

Compliance Manager

Actuarial Analyst III

Actuarial Analyst III

Nurse Case Manager II

Respiratory Therapist

Business Change Director

Senior Documentation Analyst

Senior Billing Specialist, Pharmacy

Application Developer – Engineer I

Operations Intern

Sales Support Specialist – BioPlus Specialty Pharmacy

Account Executive III

Bilingual Nurse Practitioner – 100% Virtual