Own the development and maintenance of clinical and reimbursement policies, ensuring perfect alignment with CMS regulations.
Design and oversee a robust audit program that monitors adjudication system output against clinical policies, pricing, benefit rules, and provider contract terms.
Lead the implementation of AI initiatives to automate the monitoring of reimbursement policies and contract validation.
Accountable for the development and maintenance of clinical and reimbursement policies, ensuring alignment with CMS regulations.
Serve as the authority on Medicare guidelines, specifically interpreting and operationalizing NCDs, LCDs, and national coding guidelines.
Lead the implementation of AI initiatives to automate the monitoring of reimbursement policies.
Clover Health focuses on improving the health of its members by leveraging technology and data-driven insights to provide personalized, high-quality care. They aim to empower their members by helping them navigate the complexities of healthcare and live healthier lives and are passionate about making healthcare easier, more affordable, and more accessible for everyone.
Research and document new payment integrity concepts by analyzing medical policies, billing regulations, and reimbursement logic.
Translate complex billing rules into precise technical specifications for automated claim auditing algorithms.
Conduct hands-on data analysis using Microsoft Excel to explore datasets and quantify savings potential for clients.
Cohere Health's clinical intelligence platform delivers AI-powered solutions that streamline access to quality care by improving payer-provider collaboration, cost containment, and healthcare economics. They work with over 660,000 providers and handle over 12 million prior authorization requests annually. The Coherenauts who succeed here are empathetic teammates who are candid, kind, caring, and embody their core values and principles.
Oversee enrollment and billing operations across all Government Programs including Medicare Advantage, Medicare Supplement, CHIP, and ACA products to ensure accuracy and operational performance.
Lead Medicare Advantage appeals and grievances operations to ensure timely, compliant resolution and audit readiness in accordance with CMS requirements.
Drive process improvement initiatives and cross-functional coordination to enhance regulatory outcomes, member experience, and operational efficiency.
Capital Blue Cross is a health insurance company and independent licensee of the Blue Cross Blue Shield Association that promises to go the extra mile for its team and community. It is consistently voted one of the 'Best Places to Work in PA,' fosters a flexible environment prioritizing health and wellbeing, and invests heavily in employee training and continuing education.
Provide strategic management oversight in designing, implementing, directing, and monitoring the Alliance’s Risk Adjustment Department functions.
Direct the Risk Adjustment Department, act as a subject matter expert, and provide executive-level advice and guidance on coding and risk adjustment methodologies and overall business operations.
Direct, manage, and supervise Risk Adjustment Department staff
Central California Alliance for Health is a regional non-profit health plan. They are committed to providing accessible, quality health care guided by local innovation, with over 500 dedicated employees and a culture that is respectful, diverse, professional and fun.