Medica

Risk

• Provide enterprise leadership to design, standardize, and improve the end to end operating model across HEDIS and Risk Adjustment
• Drive improvements in data collection, processing, encounter creation and management, submission controls, reconciliation, and audit readiness
• Ensure execution across internal teams, technology partners, analytics, finance, and external vendors is aligned and coordinated
• Establish and maintain governance structures for regulatory compliance, audit readiness, and defensible outcomes
• Own the end to end vendor operating model for Risk Adjustment
• Serve as the primary integrator across Quality, Performance Outcomes, Technology, Data, Analytics, Finance, Actuarial, Provider Quality, and external partners

Senior Director, Risk Adjustment

Manager

• Provide member-centered, evidence-based model of care
• Understand individual care goals and coordinate care
• Assist in finding community resources
• Reduce illness burden for individuals and families

Transplant Case Manager

Customer Support

• Resolve service inquiries for claims, enrollment, billing, pharmacy
• Work telephonically
• Provide exceptional levels of service satisfaction
• Utilize the service recovery process to assist members in complex situations
• Participate in fast-paced and rewarding environment with paid training

Customer Service Representative – Government Products

• Resolve service inquiries for claims, enrollment, billing, and pharmacy
• Explain benefits and interpret contracts
• Provide exceptional service satisfaction
• Utilize service recovery process for complex situations

Customer Service Representative – Commercial Products

Auditor

• Audits claims for coding accuracy, benefit payment, contract interpretation, and compliance with policies and procedures
• Gathers findings at a macro level and makes recommendations for process improvement and efficiencies
• Performs professional responsibilities with direct supervision on method and processes
• Performs other duties assigned

Quality Auditor

Program Manager

• Lead enterprise-wide strategy for CAHPS and HOS performance across Medicare contracts
• Translate CMS Stars methodology and cut point trends into actionable insights and improvement plans
• Partner with leaders across Quality, Stars, Member Engagement, Operations, Marketing, and Member Experience to align initiatives with Medica’s strategic roadmap
• Manage end-to-end CAHPS and HOS program cycles, including survey preparation, vendor coordination, and post-survey analysis
• Oversee timelines, deliverables, and compliance with CMS protocols
• Develop and maintain dashboards, forecasts, and performance tracking tools
• Collaborate with teams across Member Experience, Population Health, Operations, Health Equity, Provider Quality, and Communications
• Facilitate provider engagement strategies to improve member experience and functional health outcomes
• Support internal and external reporting, including Board updates and provider-facing materials
• Monitors and analyzes member experience indicators and Medicare CAHPS survey results, identify performance drivers, and lead root cause investigations to ensure goals, objective and outcomes are met
• Monitor year-over-year trends, forecast performance against CMS cut points, and recommend targeted interventions
• Translate complex data into executive-level summaries and strategic recommendations
• Works with health plan, providers, and vendors to review best practices, programs, and processes for improvement opportunities

Senior Program Manager

• Mentor and manage a team of contract managers, guiding them through complex negotiations
• Lead and support contract negotiations with providers to secure favorable terms
• Oversee the entire contract lifecycle from initiation to execution, monitoring, and renewal/termination
• Ensure all contracts comply with federal, state, and industry standards
• Analyze contract performance, monitor financial metrics, and recommend improvements
• Foster and maintain strategic relationships with provider partners
• Develop and maintain policies, procedures, and templates for contracting
• Liaise with other departments to ensure accurate implementation of contract terms

Manager, Provider Contracting

• Develop and maintain provider networks yielding a competitive, geographic, stable network that achieves objectives for unit cost performance and trend management
• Produces an affordable and predictable network for customers and business partners
• Evaluates and negotiates contracts in compliance with company contract templates, reimbursement structure standards, and other key process controls
• Establishes and maintains strong business relationships with Hospital, Physician, Pharmacy, or Ancillary providers, and ensures the network composition includes an appropriate distribution of provider specialties
• Manage contract renewals and amendments: Track critical dates, manage the renewal process, and handle amendments as needed
• Oversee the entire contract lifecycle: Manage all stages, from initiation and negotiation through execution, monitoring, and closure
• Manage provider relations, address issues, and lead dispute resolution processes
• Regularly evaluate the performance of assigned networks and providers to identify areas for improvement
• Participate in activities related to network adequacy, provider recruitment, and marketing for providers

Provider Contracting Manager III

• Provide a member-centric, evidence-based model of care across multiple products
• Conduct comprehensive assessments
• Develop, implement, and monitor individualized care plans
• Coordinate services across the healthcare continuum