Elevance Health

Program Manager

• Provides strategic planning analysis to ELT concerning staffing needs
• Provides strategic direction for developing enterprise project plans
• Provides expert knowledge of project management methodology to senior management
• Directs system analysts, software designers and programmers to meet project objectives
• Coaches and mentors project team members; determines project scope

Technical Program Director

Clinical Operations

• Oversees pharmacist and pharmacy intern associates developing and configuring prior authorization decision trees in the PA workflow tool.
• Oversees associate performance and quality assurance of prior authorization decision trees within the PA workflow tool.
• Provides clinical consulting services to internal partners.
• Assists in implementing clinical programs within the prior authorization space.
• Assists in the development of new clinical products.
• Oversees the Prior Authorization Center.
• Implements new prior authorization programs.
• Manages clinical pharmacy operations and staff to ensure clients' objectives and deliverables are met.
• Oversees departmental processes, policies and procedures, training, and communication.
• Reports and analyzes prior authorization program trends.
• Ensures achievement of department goals and objectives.
• Hires, trains, coaches, counsels, and evaluates performance of direct reports.
• Provides clinical consulting services to client and implements clinical information and education programs.
• Assists in developing formularies.
• Performs drug utilization analyses.
• Participates in and presents to Pharmacy and Therapeutics (P&T) committee meetings and management of client formulary.

Manager, Pharmacy Clinical Operations – Clinical Configuration

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 customers' 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
• 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

Senior Account Service Manager – Carelon Payment Integrity Commercialization

• Managing autism services and behavioral health treatment benefits through written review
• Using appropriate screening criteria knowledge and clinical judgment to assess member needs
• Ensuring access to medically necessary quality behavioral healthcare in a cost effective setting
• Referring cases to Peer Reviewers as appropriate
• Performing ABA initial treatment assessment reviews and treatment monitoring
• Evaluating to promote quality member outcomes to optimize member health benefits
• Serving as a resource to other BH Care Managers
• Assisting with more complex cases
• Participating in inter and intradepartmental teams projects and initiatives

Behavioral Health Care Manager II – ABA

Business Analyst

• Conduct outbound provider calls to confirm that services were rendered, and that the provider was expecting payment
• Review claim details to determine claim validity before initiating outreach, ensuring all required information is accurate and complete
• Meet or exceed daily outbound call attempt requirements as established by departmental performance metrics
• Maintain a QA (Quality Assurance) score of 95% or higher
• Provide excellent customer service when interacting with providers
• Document call outcomes and follow-up activities in required systems
• Review and evaluate payment integrity recovery requests from external partners

Provider Outreach Business Analyst II

Medical Director

• Supports the Medical Management staff to ensure timely and consistent responses to members and providers.
• Provides guidance for clinical operational aspects of a program.
• Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations.
• Interprets existing policies or clinical guidelines and develops new policies based on changes in the healthcare or medical arena.
• Leads, develops, directs and implements clinical and non-clinical activities that impact efficient and effective care.

Performance Medical Director

Product Manager

• responsible for the development of products in both new and existing markets
• Focus on the business case product strategy/definition/positioning roadmap development
• portfolio management
• full competitive analysis
• win/loss analysis
• forecasting and value delivery through the ecosystem
• Evaluate existing products, competitor data, and industry data to improve existing products as well as make recommendations for new products
• Develop and implement new product design, streamlined system enhancements, and escalated issue resolution
• Utilize the right key performance indicators (KPIs) to measure the product performance
• Facilitate meetings, presentations, and demonstrations for all audience levels
• Manage stakeholder communications and expectations
• Responsible for the end-to-end implementation of all phases of product development
• Gather business requirements/product capabilities then provide the translation to our Digital and Strategy partners
• Ensure all products are compliant with regulatory directives, state/federal laws, and policies
• Serve as a product expert and a relationship manager to the core clients
• Collaborate with the system and solution architects to assist with decision-making and sequencing of the key technical aspects to support the new business functionality

Agile Product Manager

• Responds to more complex cases and account specific requests
• Uses appropriate screening criteria knowledge and clinical judgment to assess member needs
• Conducts assessments to identify individual needs and develops specific care plan to address objectives and goals
• Monitors and evaluates effectiveness of care plan and modifies plan as needed
• Supports member access to appropriate quality and cost effective care
• Coordinates with internal and external resources to meet identified needs of the members and collaborates with providers
• Serves as a resource to other BH Case Mgrs.

Behavioral Health Care Manager II

Medical Billing and Coding

• Responsible for comprehensive analysis of claims data to generate refined and industry-relevant concepts
• Engages with providers and stakeholders for collaboration in reviewing coding and documentation guidelines
• Examines medical records to ensure precision of code assignment
• Provides feedback to providers on coding guidelines and industry expertise
• Conducts analyses of claims data to support educational concepts

Medical Coding Education Associate, Certified

Actuary

• Completes Actuarial Experience Reports including data collection and Category of Service logic
• Leverages IBNR models and reconciles to the general ledger
• Provides support for Audits by explaining models and data
• Obtains, verifies, analyzes and models data including risk reporting and forecasting
• Calculates monthly claims liability reserves and develops merit rating factors
• Prepares Department of Insurance annual statement exhibits

Actuarial Analyst II

• Responsible for managing psychiatric and substance abuse or substance abuse disorder facility-based and outpatient professional treatment health benefits through telephonic or written review
• Uses appropriate screening criteria knowledge and clinical judgment to assess member needs to ensure access to medically necessary quality behavioral healthcare
• Refers cases to Peer Reviewers as appropriate
• Performs psychiatric and substance abuse or substance abuse disorder assessment coordination implementation case planning monitoring and evaluating to promote quality member outcomes to optimize member health benefits

Behavioral Health Care Manager I, Utilization Management

• Responsible for the comprehensive analysis of complex claims data
• Generate refined and industry-relevant concepts that govern the prosperity of the company across all business lines and client interactions
• Engage with providers and other internal/external stakeholders to ensure proactive collaboration in reviewing coding and documentation guidelines
• Examine medical records and various documentation to ensure the precision of code assignment
• Research, validate, and stay abreast of medical coding and billing issues, trends and changes in regulations and industry standards
• Develop concept ideas to support the goals of the department and organization
• Launch education concepts
• Furnish providers with comprehensive feedback on current year coding guidelines and industry expertise
• Assist other associates with their documentation and education discussions
• Execute a detailed review of medical records to confirm documentation justifies the level of service provided
• Assist other associates with the completion of medical record reviews and respond to provider inquiries
• Complete appeals requests from providers

Senior Medical Coding Education Associate – Hospital / Professional Claims

Vice President

• Develop and implement a comprehensive strategy and plan to integrate govt. business strategy across all DPAIO functions to ensure actions for profitable growth.
• Act as a strategic advisor for multiple business units of Medicare, Medicaid and Duals etc.
• Drive initiatives that enhance customer experience by collaborating with key customer-facing health plans and central MA, duals functions and interface with all leaders for govt business across functions to suggest evolution of the business models.
• Identify opportunities for technology-driven business capabilities, ensuring business growth with an agile mindset.
• Establish KPI’s and metrics to measure the effectiveness of how technology enables the new business models and size the opportunities for execution.
• Integrate customer needs and feedback into the digital technology roadmap identifying new opportunities.

Staff Vice President – Government Business, Technology Enablement

Director

• Oversees case and utilization management execution/decision making for managed member populations.
• Is accountable to plan executive or executive team member dependent on plan size/complexity and is involved in the development of the strategic vision, goals, and objectives for medical management.
• Serves as liaison to state regulatory agencies.
• Drives direction of the plan related to cost of care and other plan directives.
• Ensures program compliance and identifies opportunities to improve the consumer experience and quality outcomes.
• Directs and provides leadership for designing, developing, and implementing integrated medical management program to meet the demographic and epidemiological needs of the populations serviced.
• Partners with other health plan/corporate leaders to develop and deliver innovative care management services, root cause analyses and solutions to achieve quality outcomes.
• Directs Healthcare Management Program including disease management, case management, and utilization management.
• Partners with Provider Relations, Quality Management, Health Promotions, and Community Relations to develop and implement effective provider communications, quality assurance, and member outreach programs.
• Provides expert consultation to local plan staff on benefits interpretation and utilization and quality management matters.
• Ensures support for compliance with National Committee for Quality Assurance (NCQA) and assures compliance with state/and or federal program requirements.

Senior Director, Healthcare Management Services

Human Resources

• Partner with a cross-functional group of subject matter experts
• design and execute the strategy for staffing, onboarding, developing, motivating, and retaining work
• Execute programs to support associates, including compensation, performance management, organizational design, succession planning, diversity and inclusion, organization culture, rewards and recognition, and talent management
• Provide insightful data to guide decision making and offer proactive solutions
• Consult with mid-level and line managers to create comprehensive people plans
• Design and quickly implement solutions cutting across multiple disciplines
• Analyze data, understand trends, and develop recommendations for action