Gainwell Technologies

Manager

• Responsible for defining, managing, and improving the quality of services related to dental consultant clinical support, dental services, dental policy, and provider training.
• Collaborates with stakeholders to meet SLAs and KPIs, monitors performance, and takes corrective action as needed.
• Partners with operational and system teams, clients, and external vendors on policy, process, and workflow reviews, while overseeing daily business operations to optimize processes, manage resources, and ensure efficiency and productivity align with company goals.
• Manage the day-to-day activities to ensure dental consultant clinical support, dental services, dental policy, and provider training operations runs smoothly and efficiently.
• Develop and implement strategies to improve policy, workflows, productivity, and quality standards.
• Supervise, hire, train, and mentor employees to meet performance expectations and company goals.
• Oversee budgets, manage resources effectively, and negotiate with vendors and suppliers if called upon.
• Track key performance indicators (KPIs) to analyze performance and make data-driven decisions for improvement.
• Ensure projects have well-documented requirements, partner with cross-functional teams to pursue project development and Go Live deployment.
• Handle special projects as assigned.
• Contribute to long-term planning and align daily operations with strategic objectives.

Dental Services and Clinical Policy Manager

Customer Support

• Provide knowledgeable responses to basic client questions; elevate more complex cases to appropriate staff as needed
• Put your skills to work to solve client problems, update account history and follow up with clients to confirm their inquiry or request is resolved
• Adhere to the client’s SLAs and consistently meet production targets
• Collaborate with team members, management and clients to resolve client inquiries; cross-train new resources in customer service processes
• Process client inquiries more efficiently and effectively by reviewing and recommending changes to procedures and workflow

Senior Customer Support

Financial Planning and Analysis

• perform a variety of responsibilities within the Cash Operation team to support daily financial activities
• verify daily fund inflows and outflows, ensuring accuracy in banking information and spreadsheet data
• communicate professionally with internal and external customers through telephone and email channels
• post provider payments and maintain accurate, organized transaction records
• process State directives and manage mail-related preparation tasks with a high level of attention to detail

Financial Services Representative

Auditor

• Review and verify insurance claims for accuracy, completeness, and compliance with policy terms and regulatory requirements
• Audit claim files and analyze claim payment accuracy, including complex claims
• Review and interpret Explanation of Benefits (EOB), Explanation of Payment (EOP), and Remittance Advice documents
• Identify inconsistencies, discrepancies, or potential errors and escalate findings to the appropriate teams for resolution
• Ensure claim payments align with company procedures, contractual guidelines, and regulatory standards
• Collaborate with management and claims processing teams to research and resolve claim issues
• Maintain current knowledge of state and federal regulations related to insurance claims and compliance requirements
• Prepare audit documentation, reports, and summaries outlining findings and recommendations

Healthcare Claims Auditor

Director

• The Quality Management Director serves a critical function providing review and monitoring of services provided by Gainwell on the Medi-Cal account.
• Responsible for the quality management program and is the primary point of communication with the client.
• Set the strategy and vision for the account’s Quality Management activities including Quality Assurance, Quality Control and reporting.
• Provide structure, methodologies and direction for root cause analysis, corrective actions and ongoing process improvements.
• Manage all account quality management activities as well as provide leadership and support to the quality management team.

Quality Management Director

Claims Specialist

• Review, research, and update health insurance coverage;
• Submit and bill medical claims to insurance carriers;
• Conduct casualty and trauma claim reviews;
• Manage premium payments to external carriers and reconcile any premium discrepancies.

Health Insurance Claims Analyst

• Processes moderately complex claims for Alaska Medicaid client.
• Makes decisions on payment of medical claims using existing policy and rules.
• Reviews and researches suspended medical claims and adjudicates them per DHS policy.
• Refers claims to Utilization Review and Provider Services units.
• Maintains necessary documentation.
• Participates in meetings as necessary.
• Participates in process improvement sessions.
• Trains as a back-up for other areas, such as document control, courier, and customer service desk.

Call Center Representative

• Identifies, prioritizes, and resolves most questions
• Receives calls and provides accurate, acceptable answers to queries and concerns
• De-escalates situations involving dissatisfied callers, offering patient assistance and support
• Guides callers through troubleshooting and navigating the Medicaid sites and/or services
• Reviews customer or client accounts, providing updates and information per established program policies

Call Center Specialist

Business Analyst

• Assist in tracking, managing and processing compliance incidents within the Medi-Cal Dental Program
• Query reports and analyze data surrounding the delivery, billing, and utilization of dental services to detect unusual practices, billing anomalies and potential abuse by Medi-Cal dental providers and/or members
• Facilitate internal and external department meetings, including establishing calendar invitations and formulating formal agendas
• Record, capture, publish and disseminate detailed meeting minutes for Performance Management
• Assist in documentation of activities surrounding providers and remediation activities.

Performance Management Business Analyst

• Review claim files to identify subrogation opportunities and confirm third-party liability
• Assess and value medical claims in accordance with applicable policy coverage and program requirements
• Analyze claim reports, medical records, and loss documentation to support valuation decisions
• Prepare detailed and well-supported valuation reports for subrogation demands and recovery efforts
• Validate claim quantum for negotiation, mediation, arbitration, or litigation support
• Ensure all valuations are complete, accurate, and supported by appropriate documentation
• Collaborate closely with recovery managers, call center teams, intake personnel, and internal stakeholders
• Support timely, compliant claim processing aligned with Gainwell standards and client expectations

Subrogation Claims Analyst

Designer

• Conduct discovery sessions with stakeholders to gather functional requirements for document templates, including data mapping and business logic.
• Utilize Exstream Designer/Design Manager to create and maintain high-volume, on-demand document templates.
• Map complex input data (XML, JSON, CSV) to document variables and define conditional logic for personalized content.
• Support System Test team as well as the client during User Acceptance Testing (UAT) to ensure document accuracy and compliance.
• Identify opportunities for automation and template consolidation to improve operational efficiency.
• Author detailed Business Requirement Documents (BRDs), functional specifications, and technical design documents.

Exstream Designer

• Serve as the primary functional liaison between the client, MCOs, and internal technical teams
• Lead requirements gathering sessions and triage meetings to address defects and operational gaps
• Analyze and document complex requirement issues
• Investigate root causes of systemic issues reported by Providers or MCOs
• Support the Compliance Manager in assessing the impact of new mandates on current system functionality

Business Analyst – Medicaid MMIS

Data Analyst

• Develop and maintain ad-hoc reports and dashboards
• Design, develop, and validate analytics and delivery documentation to support the PHM Service
• Implement and maintain complex databases
• Provides overall monitoring of standards and procedures
• Applies data analysis or data modeling techniques

Analyst

• Reconciling and designating Drug Rebate payments in the Drug Rebate system at the National Drug Code level
• Researching and responding to DHCS and drug manufacturer inquiries via email
• Tracking incoming manufacturer documentation
• Mailing invoices and late payment notice letters
• Completing daily status reporting of work performed
• Handling company confidential data according to policy and guidelines

Drug Rebate Analyst

Learning and Development

• Conducts training courses, both on-site and on-line, for non-technical skills training to include lectures, web-based programs and hands-on sessions.
• Works with applicable business unit/area to establish specifications of course, prerequisite skills and knowledge for trainees.
• Prepares lesson plans and assists in developing and preparing training materials such as manuals, handouts, instructor guides and audiovisuals.
• Gathers and summarizes course evaluations to provide data for review by senior level trainers to determine effectiveness of training sessions.
• Assists in the review of external training programs to determine feasibility of purchase.