Luminare Health

Business Operations

• Responsible for the maintenance, revision, and implementation of Policies and Procedures to ensure compliance with applicable regulatory standards and contractual obligations
• Prepare, develop and make recommendations by analyzing reports and operational data to support operational improvements and enforcement of established standards
• Work collaboratively with overall operations management team to develop operational efficiencies, maintain contractual requirements, and overall compliance of core operations is in conformity with various rules and regulations
• Conduct continual research of new and revised accreditation and regulatory standards applicable to CMS in collaboration with external PSERS vendors
• Maintain a database of regulatory requirements applicable to PSERS processes
• Responsible for the ongoing maintenance and revision of PSERS Division and Utilization Management Policy
• Acts as the Department Liaison for maintenance of required Regulatory Filings/Reports and CMS Inquiries
• Collect, analyze and report on key metrics inclusive of identifying trends, barriers, conducting root cause analysis when applicable and providing objective recommendations
• Recommend process improvements for every day operating procedures
• Assist with the ongoing analysis of the PSERS Program to identify opportunities for process improvement, reengineers processes to improve efficiencies and to ensure compliance
• Provide expertise in regulatory/accreditation issues/inquiries for all PSERS functional areas
• Maintain a positive and educational approach when interacting with both internal and external customers in explaining the Regulatory Compliance Program wants and needs
• Assist with the orientation of personnel and positively contribute to the ongoing networking of expertise with colleagues
• Compile information via data sources and provide back up support for system administration collecting, analyzing, and summarizing information.
• Work collaboratively with management team to work on identified trends and issues for short term and long term resolution, leveraging people, process, technology, and team communications/tools are updated.
• Promptly review Medicare Part A/D changes and determine impact to PSERS operations
• Share the information with operational team and assess impact, implementing changes as needed, to ensure proper tools and educational information is shared with front line team members or impacted individuals
• Review eligibility and customer service audits, as well as Medicare program audits, to assess steps needed to be taken to correct issues, report and respond to CMS.

Business Operations Specialist

Analyst

• Perform project activities including gathering and documenting business needs and requirements
• Establish test plan and develop test scenarios
• Assist in testing processes
• Work closely with team members to document user stories (requirements) and acceptance criteria
• Participate in testing activities for each development phase

Requirements Analyst

Business Intelligence Analyst

• Own the definition, standardization, and governance of operational performance metrics and KPIs
• Ensure consistent application of metric definitions across reports, dashboards, and deliverables
• Maintain reporting calendars, distribution protocols, and version control standards
• Produce and deliver executive-level dashboards, scorecards, and performance summaries
• Lead preparation of SLA reporting and performance guarantee assessments
• Translate operational results into clear narratives, key takeaways, and recommended actions
• Coordinate and deliver performance-related reporting for regulatory, accreditation, and client audits
• Ensure reporting outputs align with contractual and regulatory requirements
• Drive standardization, automation, and scalability of recurring performance reports
• Identify opportunities to streamline reporting workflows and reduce manual effort
• Establish quality review checkpoints for performance reporting deliverables

Senior Performance Reporting Analyst

Data Analyst

• Sourcing, transforming, validating, and analyzing data to support performance reporting, operational analytics, and regulatory needs
• Extracting data from core systems, including claims, enrollment, provider, utilization management, call center, and financial systems
• Developing and maintaining SQL queries, views, and data models to support reporting and analytics needs
• Performing data transformations, joins, and aggregations to create analysis-ready datasets
• Supporting data ingestion and integration across multiple source systems
• Performing data validation, reconciliation, and quality checks to ensure accuracy, completeness, and consistency
• Investigating and resolving data anomalies in collaboration with IT, vendors, and business stakeholders
• Documenting data sources, logic, and transformation rules
• Conducting exploratory and ad-hoc analysis to answer operational and business questions
• Supporting root cause analysis and investigative work requested by performance and operations teams
• Identifying data trends, anomalies, and patterns that may impact operational performance
• Delivering validated datasets and analytical outputs to Senior Performance Reporting Analysts and reporting teams
• Supporting the development of dashboards and reports by ensuring that underlying data is accurate and performant
• Assisting with performance metric calculations as defined by reporting governance
• Collaborating with data engineering and IT teams on data warehouse, data mart, and reporting layer enhancements
• Supporting automation of data pipelines and recurring analytical processes
• Participating in data governance, metadata management, and documentation initiatives

Data Analyst – Business Transformation

Client Partner

• Responsible for building and maintaining consultative and strategic partnerships with assigned book of business
• Works directly with sales executives during finalist presentations
• Expected to support and service between 12 – 20 clients
• Maintains senior management-level contact with client stakeholders and the broker
• Internal project participation that benefits and supports the client and/or client management organization
• Charged with retaining and growing their assigned book of business

Client Manager

Claims Specialist

• The Claims Analyst is responsible for the accurate adjudication and processing of medical, dental, vision, or other related claims, including related correspondence and/or electronic inquiries for assigned groups.
• Review, analyze and interpret claim forms and related documents.
• Determine benefit coverage based on clinical edits, plan documents/booklets, benefit reference documents, Claim Reference Manuals and claims-related memoranda, and reports.
• Appropriately investigate, pend and refer claims based on claim procedures and guidelines.
• Accurately handle correspondence, claims, and referrals in the established timeframes and/or performance guarantees.
• Support the Claims reinsurance team, in the research and resolution of claims as assigned.
• Support internal departments in the research and resolution of claims.
• Communicate via telephone, email, electronic messaging, fax, or written letter with employees/members, providers of service, clients and/or other insurance carriers to ensure proper claim processing.
• Provide responsive and caring customer service.
• Resolve issues through effective oral and written communication and by involving appropriate people within, or outside, the department or Company.
• Effectively and professionally represent the Company in all interactions.

Claims Analyst

Operations

• Responsible for hands-on training of regional staff using corporate curriculum, procedures and documentation
• Training areas include any Operations function, industry and compliance topics, system releases, new products or clients, and other regional or corporate initiatives
• Responsible for reviewing and integrating all information produced and distributed by Luminare Health Corporate Training

Operations Trainer

• Retaining and growing revenue for the assigned book of business
• Exceeding client expectations surrounding service excellence
• Building and maintaining consultative and strategic partnerships with assigned book of business
• Supporting and servicing between 12 – 20 clients in the West Coast region
• Participating in internal projects that benefit the client management organization

Client Manager – West Coast

Procurement

• Developing and managing strategic sourcing and vendor relationship partner strategies for assigned vendors
• Managing the selection, acquisition and monitoring of contractual agreements for Business Operations
• Working closely with Business Operations Partners to understand their needs
• Serving as the central point of contact for purchases, deliveries and challenges related to products and services
• Articulating and negotiating service level agreements
• Driving partnerships with vendors to optimize service delivery and operational efficiency

Vendor Management

Manager

• Responsible for leadership, management, and execution of a wide scope of operational processes and workflows
• Direction and development of the Implementation Managers
• Manage the cross-functional activities involved with the implementation phase for new clients, new products, or other regulatory or vendor changes impacting clients
• Active participation in developing project plans, outlining tasks to be completed, including timeframes
• Expert operational knowledge and strong operational leadership ability
• Highly interactive position working with peers in many functional areas
• Help mitigate client risks and internal risks through comprehensive understanding of all downstream impacts
• Client facing and may require occasional travel

Senior Manager, Implementation

• responsible for the daily operations of Clinical Review Department in Healthcare Management
• collaborate with the Associate Director
• oversight and accountability for the assigned staff performing Utilization Management and Claims Medical Management functions
• support work for the Utilization Review Program
• conduct analysis of data as it relates to the Healthcare Management processes and outcomes
• determine trends, staffing needs and risks to improve the overall effectiveness and efficiency of the department.

Senior Manager, Clinical Review

• Responsible for building and maintaining consultative and strategic partnerships with assigned book of business through the entire client life cycle
• Works directly with sales executives during finalist presentations and may be asked to present to potential clients
• Expected to support and service between 12 – 20 clients
• Maintains senior management-level contact with client stakeholders and the broker
• Internal project participation that benefits and supports the client and/or the client management organization
• Charged with retaining and growing their assigned book of business

Client Manager – Hospital, Health Systems

Director

• Develop and execute the Luminare Health Hospital strategy and product roadmap in partnership with the Executive Director of Strategic Partnerships, the VP of Client Management and the Chief Growth Officer.
• Serve as the Executive Sponsor to large, complex Hospital System clients.
• Engage with the clients at a strategic level helping them execute on their strategic priorities.
• Work closely with Client Managers and Relationship managers on day-to-day client/broker issues as well as high priority issue resolution.
• Address and resolve complex client issues with a sense of urgency by assisting with escalations, ensuring client satisfaction and loyalty.
• Lead and mentor the client management team, ensuring effective guidance, performance oversight, and adequate staffing.
• Collaborate with training and compliance to support onboarding and continuous education, including industry updates, regulations, and product trends.
• Monitor KPIs to drive client satisfaction, retention, revenue, and service excellence.
• Provide high level of customer service to all internal and external constituents by working proactively across department to meet client deliverables as well as providing timely and equitable issue resolution.
• Represent the client's perspective within the organization, ensuring their needs are understood and addressed by various departments.
• Collaborate cross-functionally with sales, marketing, and product teams to deliver a seamless client experience.
• Partner with sales to understand prospect needs, tailor solutions, and support finalist presentations and RFP responses.
• Lead market-based planning for the client engagement team, evaluate RFP performance, and gather market insights to inform product, process, and technology enhancements.
• Establish a framework to capture and act on feedback related to offerings, pricing, and contracts.
• Build and nurture strong relationships with key clients and brokers, acting as a trusted advisor and advocate for their needs within Luminare Health.
• Identify and pursue new business opportunities within existing client relationships and through new client acquisition.
• Other duties as needed/assigned.

Executive Director, Client Management – Hospitals and Health Systems

Backend Engineer

• Accountable for IT infrastructure design outcomes to meet business and user requirements:
• Oversee key infrastructure services including but not limited to: Database engineering and administration, disaster recovery, performance and capacity management, infrastructure vendor management
• Roadmap, lifecycle, OS/software/hardware
• Create and maintain design documentation, including for the use of support areas
• DR Planning alignment, including supporting design and plan creation
• Create and maintain operational control limits including visible dashboards and reports
• Create Monitoring requirements, along with ongoing controls and metrics
• Design back up requirements, including appropriate metrics and ongoing oversite with operations
• Oversite and support of vendor escalation contacts/processes
• New/upgraded technology implementation
• Stay current on emerging technologies and how they apply to your area
• Collect business requirements, to support final designs and documentation for ongoing support
• Translate business requirements to solution proposal
• Provide presentation of recommendations, risks and timelines
• Document design business case materials as required
• Identify third party vendors to implement design initiatives
• Document scope and costs of design budget requirements and initiatives. Present formal proposals up to the C level of Luminare Health. Upon approval, develop SOW and final pricing with Vendors as necessary
• Oversite of third-party vendor implementation (governance)
• Completion of as built documentation (leveraging third party implementer if necessary)
• Govern and hand off requirements to run support teams any initiatives and/or new requirements
• Participate and own active problem management as applicable
• Escalation point for support issues as needed
• Support all major incident activities as needed (oversite of all Infrastructure MI's)
• Participate in Budget process and annual planning. Document and present as required
• Support design associates technically, personal growth and overall performance management
• Perform other assigned duties as necessary to support Develop and maintain stakeholder relationships within the business and IT:
• Provide status, metrics and support to meet IT and business objectives
• Understand business requirements
• Develop and use collaborative relationships to facilitate the accomplishment of work and business goals
• Drive aligned actions, initiatives and projects
• Provide support and/or solutions to support business needs and improving end user experience
• Develop and deliver presentations supporting delivery, initiatives and projects Develop and maintain partner relationships:
• Lead effective governance models supporting desired outcomes and contractual obligations
• Align partners with business requirements enabling optimization, solutions and improvement to end-user experience
• Drive lower cost solutions to meet business requirements
• Facilitate and foster partner/ business relationships Manage and align direct reports to meet IT, business and individual objectives

Infrastructure Director – Database Engineering, Performance

• Act as the liaison between a patient and the healthcare community
• Assess, plan, implement, coordinate, monitor, and evaluate options
• Engage with patients, primary care physicians, and other providers