Elevance Health

Pharmacist

• Facilitates learning events that are performance-based in nature and across multiple platforms
• Delivers synchronous and asynchronous learning events using varied media in virtual and on-site environments
• Employs rapid course development methodologies to quickly meet client needs
• Measures, tracks and evaluates learner and client satisfaction

Trainer – BioPlus Specialty Pharmacy

Consultant

• 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
• 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, which may include monitoring reports and work flow to provide recommendations on productivity and efficiency improvements
• Updates and monitors departmental processes and procedures in compliance with system, regulatory and business requirements

Group Underwriter Consultant

Medical Director

• Responsible for appeal reviews for physical health medical services
• Ensure the appropriate and most cost-effective medical care is received
• Develop and implement programs to improve quality, cost, and outcomes
• Provide clinical consultation and serve as clinical/strategic advisor to enhance clinical operations
• Identify cost of care opportunities
• Supports clinicians to ensure timely and consistent responses to members and providers
• Provides guidance for clinical operational aspects of a program
• Conduct peer-to-peer clinical case reviews with attending physicians or other ordering providers
• Serve as a resource and consultant for other areas of the company

Medical Director – Oncology

• Design and implement innovative pharmacy programs to manage traditional and specialty drug costs under both medical and pharmacy benefits
• Research and synthesize detailed clinical data related to pharmaceuticals
• Prepare and present therapeutic class reviews and drug monograph information to the Pharmacy and Therapeutics Committee
• Serve as a clinical resource to other pharmacists on areas such as prospective, inpatient and retrospective DURs and provides dosage conversion and clinical support for therapeutic interventions
• Prepare information for network physicians

Clinical Pharmacist, Clinical Pharmacy Strategy Team

Manager

• Effectively manages the provider relations and contracting team
• Ensures access to high-quality LTSS services and cost efficiency
• Oversees provider contracting strategies
• Builds and maintains strong relationships with provider organizations, advocacy groups, and regulatory partners
• Hires, trains, coaches, counsels, and evaluates performance of direct reports

Manager, Provider Network Management

Customer Support

• Responds to customer questions via telephone and written correspondence
• Analyzes problems and provides information/solutions
• Operates a PC/image station for data extraction
• Documents information and activities in the database
• Develops and maintains positive customer relations
• Conducts follow-up telephone calls/emails to answer customer questions

Customer Care Representative

• Ensures timely completion of clinical case reviews for their board-certified specialty
• Makes physician to physician calls to gather medical appropriate information in order to make medical necessity determinations for services requested
• Makes medical necessity determinations for grievance and appeals appropriate for their specialty
• Ensures consistent use of medical policies when making medical necessity decisions
• Brings to their supervisors attention, any case review decisions that require Medical Director review or policy interpretation

Associate Medical Director – Outpatient Rehab

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
• Drawing on advanced ICD-10 coding expertise, mastery of clinical guidelines, and industry knowledge to substantiate conclusions
• 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 such as inappropriate billing for readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs)
• 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 the interpretation and data entry of moderately complex prescriptions
• prior authorization processing
• troubleshooting adjudication issues
• verifies member information and inputs data for the pharmacists
• educates members on pharmacy based rules related to prescriptions and medication resources or assistance programs
• processes prior authorization requests from physicians, offices and ensures compliance with Medicare requirements
• informs relevant parties of all prior authorization determinations
• provides resolution to grievances and appeals issues
• responds to inquiries from physicians, sales team, and members related to formulary and prescription benefits
• generates reports relating to rebates, physician utilization, Beers Criteria, Reliance members, and other ad hoc reports
• maintains record keeping of prior authorizations, rebates, and monthly reports

Pharmacy Tech II

Community Manager

• engage with members who have been identified as possessing significant SDOH barriers
• collaborates with members, interdisciplinary teams, and external stakeholders to identify goals and develop care plans that address barriers related to Social Determinants of Health (SDOH), physical and behavioral health needs, and gaps in care
• supports members in accessing healthcare services and resources, while assisting with the development, maintenance, and engagement in new relationships
• interface with Care Managers to ensure that the individualized plan is aligned with existing or needed case management efforts
• act as a liaison between community stakeholders and the health plan

Community Engagement Navigator, Region 2

• Responsible for appeal reviews for physical health medical services
• Ensure appropriate and cost-effective medical care is received
• May develop and implement programs to improve quality, cost, and outcomes
• Provide clinical consultation and serve as clinical/strategic advisor
• Identify cost of care opportunities
• Supports clinicians for timely and consistent responses to members and providers
• Provides guidance for clinical operational aspects of a program
• Conduct peer-to-peer clinical case reviews
• Serves as a resource and consultant for other areas of the company
• May represent the company to external entities and serve on committees
• Interprets medical policies and clinical guidelines
• May develop and propose new medical policies
• Leads, develops, directs, and implements clinical and non-clinical activities

Appeals Medical Director – Urology

Business Analyst

• Analyzes business needs to determine optimal means of meeting those needs.
• Determines specific business application software requirements to address specific business needs.
• Works with programming staff to ensure requirements will be incorporated into system design and testing.
• Acts as liaison with users of the software to address questions/issues.

Business Analyst II

• responsible for performing care management within the scope of licensure for members with complex and chronic care needs
• assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum
• performs duties telephonically with medical groups, providers, community resources, and members for discharge planning
• 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

RN Nurse Case Manager, HMO

Vice President

• Identify, evaluate, and execute inorganic growth opportunities
• Lead mergers, acquisitions, divestitures, and strategic partnerships
• Partner closely with finance, strategy, legal, and operations teams

Staff VP, Corporate Development – M&A

• Conduct detailed evaluations of provider practices to determine their current capabilities in value-based care and identify key areas for growth and improvement.
• Engage in a continuous process that includes assessment, root cause analysis, strategy development, implementation, and outcomes tracking for each provider.
• Assist providers with executing action plans focused on population health management, patient satisfaction, and optimizing quality and cost performance.
• Lead collaborative meetings with provider staff and internal stakeholders to ensure alignment and successful deployment of strategic initiatives.
• Create and deliver tailored learning opportunities to aid providers in implementing recommended interventions effectively.
• Educate providers on using proprietary tools, data, and technology to improve performance in critical metrics, driving effective and efficient care.
• Utilize data analytics to continuously monitor and track the key performance metrics for assigned providers, ensuring data-driven decision-making.
• Accurately document all action plans, interventions, and provider activities in Salesforce to maintain comprehensive records and reporting capabilities.
• Cultivate and maintain strong, long-term relationships with physicians, providers, and healthcare systems to support financial and quality improvements within the health plan contract.
• Advise executives on developing segment-specific strategies in areas such as financial performance, incentive programs, quality management, and other operational areas impacting provider success.
• Exercise independent judgment on complex issues, working under minimal supervision to evaluate variable factors and determine optimal courses of action.