Peak Health

Manager

• Participate in activities related to care management program build, implementation, oversight, and delegation.
• Perform utilization management reviews as needed according to accepted and established criteria, as well as other clinical guidelines and policies.
• Manage and triage member self-referrals to care management programs.
• Assist members in understanding their available medical benefits and connecting them with in-network providers and community resources.
• Identify barriers preventing the member from meeting maximum quality of life.
• Review and Evaluate Health Risk Assessment (HRA) data to help drive development of programs and services geared toward member needs.
• Review and Evaluate member outcomes data and work with other team members on performance improvement opportunities.
• Utilizing NCQA standards in auditing processes of member records as part of care management oversight processes.
• Investigating potential quality of care issues that may affect the quality or safety of the health of members.
• May review medical records and other documentation to ensure quality care.
• Assist in reviewing and updating activities and resources to address member needs.
• Participate in case management and quality committees.
• Assist in reviewing and updating policies and procedures to align with delegated processes.
• Assist in quarterly reporting of delegated case management processes to meet accreditation standards.
• Assist in submission of required documents/policies during application process to accrediting body.

Care Manager, RN

Accounts Payable

• Compiles and processes accounts payable, maintains day to day payment cycle, and provides efficient customer service.
• Verify approval on all payment requests.
• Process payments to contracted providers for claims submitted to and processed by the Claims Operations department.
• Resolves problems associated with payables transactions.
• Reconciles processed work by verifying entries and comparing system reports to balances.
• Provides accurate and effective document preparation and records management relative to the Accounts Payable function in accordance with records retention policies and procedures, and any federal regulations (if applicable).

Accounts Payable Representative

Analyst

• Review, implement and test new plan designs
• Update existing benefit plans via business requirements
• Work with IT for technical solutions
• Analyze and update CPT, HCPC and ICD-10 coding
• Ensure compliance with CMS and other insurance governance agencies
• Conduct regular audits and reviews of benefit configurations
• Resolve configuration errors and maintain documentation
• Validate medical billing codes
• Administer review of professional billing systems and perform research on coding errors
• Collaborate with clinical and non-clinical groups to manage documentation

Benefit Configuration Analyst

Claims Specialist

• Review and oversee the adjudication of claims
• Analyze and process insurance claims
• Determine whether to return, deny, or pay claims
• Screen, review, evaluate online entry, error correction, and quality control for final adjudication of claims
• Resolve claim edits and review history records
• Communicate effectively with internal and external staff
• Ensure accuracy of data entered and record maintenance
• Attend all required training classes

Insurance Claims Processor

Accounting Manager

• Premium Billing - processes the monthly premium billing cycle for ASO PEPM fees and Medicare Advantage enrollees.
• CRM Responsibilities - Research, resolve and communicate resolution to internal team as well as external vendors for any finance related customer relationship management (CRM) request(s).
• Claims Funding - Communicates weekly claims funding totals for both capitated and non-capitated claims to ASO clients as part of the weekly claims settlement process.
• Claims Settlement Analytics - Provides management with weekly claims settlement analytics and reports.
• Manages vendor information for accuracy relating to address and banking information to ensure payments to vendors are received and/or processed in a timely fashion.
• Compiles and processes accounts payable, maintains day to day payment cycle, and provides efficient customer service.

Care Manager, RN

Accounts Payable Representative

Benefit Configuration Analyst

Insurance Claims Processor

Insurance Accounting Specialist