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.
Own product requirements for Medicare FFS enrollment workflows within HealthRules Payer, including enrollment transaction processing and plan benefit package configuration.
Drive accumulator configuration requirements for deductible, out-of-pocket maximum and benefit limit tracking across claim types and benefit periods.
Evaluate CMS rulemaking cycles and annual benefit design updates to assess downstream impact on HealthRules Payer configuration and adjudication behavior.
HealthEdge provides an integrated platform of solutions that enables health plans to converge their data and harness insights to improve outcomes. We are a team of visionary, empathetic people who believe technology should remove friction from healthcare and operate with a collaborative culture focused on making a real difference for payers and their members.
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.
Clover Health aims to improve the health of its members by leveraging technology and data-driven insights to provide personalized, high-quality care. They are a mission-driven team of individuals, who are passionate about solving healthcare's most complicated problems, and strive to put members first.
Develop product requirements supporting CMS Medicare FFS provider data standards including NPI validation, taxonomy classification and provider file maintenance aligned to HIPAA requirements.
Ensure provider configuration capabilities align with CMS enrollment, credentialing and revalidation mandates including PECOS data alignment and provider directory accuracy obligations.
Translate CMS provider data regulatory updates into structured product requirements and backlog items while partnering with implementation teams to identify and remediate compliance gaps.
HealthEdge provides an integrated platform of solutions that enables health plans to converge their data and harness insights to improve outcomes. The company has a team of visionary, empathetic people who believe technology should remove friction from healthcare and operate with agility as the regulatory landscape evolves.
Take incoming requests for appeals ensuring customer service and maximizing productivity.
Work with appeals team for multiple lines of business ensuring appeal submission for review.
Maintain quality standards, remain current on updated processes, and follow SOPs and HIPAA guidelines.
Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans. They have full-service health benefit management solutions to employers, TPAs, and health plans.
Supervise day-to-day operations of assigned Utilization Management staff.
Provide full people management for assigned Utilization Management teams, including hiring and performance management.
Drive team performance against key metrics, including engagement, productivity, and quality scores.
Personify Health has created a personalized health platform, bringing health plan administration, wellbeing solutions, and care navigation together. Their data-driven solutions aim to reduce costs while improving health outcomes, empowering people to lead healthier lives.
Own end-to-end enrollment outcomes for your customer portfolio and be accountable for SLA performance and client satisfaction.
Manage an on/offshore team of enrollment specialists: set goals, build capacity plans and develop talent.
Identify and resolve root causes of client issues by coordinating cross-functional teams.
Medallion is a leading provider operations platform that eliminates administrative bottlenecks for healthcare organizations. They are one of the fastest-growing healthcare technology companies backed by $130M in funding from world-class investors, revolutionizing provider network management.
Manage end-to-end delegated credentialing operations across an assigned portfolio of payors.
Prepare, coordinate, and execute both pre-delegation and annual credentialing audits.
Build and deliver reporting packages for submission to delegated entities & payors.
Grow Therapy is a company that serves as a trusted partner for therapists growing their practice, and patients accessing high-quality care. They are powered by technology as a three-sided marketplace that empowers providers, augments insurance payors, and serves patients with over ten thousand therapists and hundreds of thousands of clients across the country.
Managing the credentialing, payer enrollment, and provider onboarding processes for physicians and advanced practice providers.
Ensuring providers are credentialed, enrolled, and maintained with commercial and government payers in a timely and accurate manner.
Maintaining provider records, monitoring credentialing deadlines, and coordinating with payers and providers.
Modena Health (MH) and Modena Allergy & Asthma (MAA) are leading and rapidly growing medical practices specializing in allergy, asthma, and immunology care, with clinics across Southern California and Arizona, and ambitious plans for national expansion. They are physician-led, hospitality-focused, and technology-enabled, committed to transforming allergy care while advancing clinical research and expanding access to cutting-edge medicine.
Review and process appeals submitted by members and providers, ensuring timely and accurate resolution.
Evaluate cases, determine next steps, and manage multiple priorities while meeting strict turnaround times.
Review clinical and medical records, summarize findings for Medical Director review, and operate within turnaround times as short as 24–72 hours.
BlueCross BlueShield of Tennessee has been helping Tennesseans find their own unique paths to good health since 1945. At BCBST, they empower their employees to thrive both independently and collaboratively, creating a collective impact on the lives of their members.
Own the full premium audit lifecycle for WC and GL lines of business, ensuring adherence to regulatory requirements.
Lead, coach, and develop a high-performing organization of managers and QA staff.
Enhance the audit customer journey to reduce friction, improve clarity, and increase audit completion rates.
ERGO NEXT's mission is to help entrepreneurs thrive by building the only technology-led, full-stack provider of small business insurance in the industry, taking on the entire value chain and transforming the customer experience. They have helped hundreds of thousands of small business customers across the United States get fast, customized and affordable coverage.
Enrolls providers new to Privia with all commercial health plans specific to the market.
Updates and maintains provider enrollment status in credentialing system, CredentialStream.
Performs follow up with health plans according to designated timeline, until Provider is PAR.
Privia Health is a technology-driven, national physician enablement company that collaborates with medical groups, health plans, and health systems to optimize physician practices. Privia Health consists of scalable cloud-based technology that reduces unnecessary healthcare costs, achieves better outcomes, and improves the health of patients and the well-being of providers.
Own the product lifecycle end-to-end: discovery, requirements, roadmap planning, feature definition, release execution, and post-launch maintenance for a pre-defined product area.
Lead product initiatives focused on healthcare enrollment, including ingestion, validation, transformation, error handling, reconciliation, and downstream system integrations.
Translate business and regulatory needs into clear product requirements, user stories, acceptance criteria, and product specifications.
Cotiviti is an equal employment opportunity employer and recruits, hires, and promotes individuals based on their qualifications. They ensure all employment decisions are administered in accordance with equal employment opportunity principles.
Lead the resolution of complex financial and benefits billing escalations to ensure accurate member financial tracking.
Perform root-cause analysis on multi-system issues, coordinate corrective actions, and reconcile claims data across platforms.
Act as the primary bridge between internal and external teams to clarify issues and expedite resolutions while communicating clearly with members.
Maven Clinic is the world's largest virtual clinic for women and families, providing clinical, emotional, and financial support through its digital platform across fertility, maternity, parenting, and menopause care. It is an award-winning, mission-driven company trusted by over 2,000 employers and health plans, with a culture recognized for innovation and as a great place to work.
Serve as the MSD team's primary subject matter authority on ACA/Patient Protection and ACA (PPACA) policy, regulation, and CCIIO program operations.
Lead development and maintenance of the MSD knowledge base, ensuring accuracy and currency of articles and related materials.
Design and deliver Marketplace domain training and mentorship for MSD Customer Service Representatives and Senior Analysts onboarding and annually for plan year refreshers.
Computer World Services (CWS) is pursuing the CMS Marketplace Service Desk (MSD) opportunity. They are committed to the full inclusion of all qualified individuals and provide reasonable accommodations to individuals with disabilities.
Own a portfolio of jurisdictions and act as the operational lead for everything regulatory that happens in those geos.
Partner closely with engineering and product to drive requirements development and shape how registration and compliance products are customized per market.
Translate policy and legal direction into operational playbooks and translate field signal back into product priorities.
Breezy is a global, two-sided marketplace company.
Serve as the primary partner for ACOs and Medicare Supplement carriers partnering with Ceresti.
Ceresti Health pioneers a technology-enabled program centered around family caregivers in dementia care and is selected by CMS to participate in the GUIDE Model. They aim to transform dementia care nationwide, with a focus on activating family caregivers by providing them with the knowledge, skills, and confidence to detect early changes in their loved one's condition.
Management and oversight of a quality team conducting quality assurance activities.
Responsible for the successful execution of the Quality Improvement Program in accordance with CMS requirements.
Plans, organizes, and directs activities of Clinical Quality, including planning, training, and staff development.
HealthEdge is committed to workforce diversity and actively encourages all qualified persons to seek employment. They provide effective and efficient solutions to complex business problems.
Build on and formalize existing VOB processes, including SOPs, training materials, QA workflows, and escalation paths for complex benefit scenarios.
Jump into claims work when the team needs coverage including payer follow-up, and root-cause analysis.
Work directly with the Product team to embed RCM logic across the full patient funnel.
Happy Health is a one-stop comprehensive sleep medicine platform. In just 5 days, patients can get an FDA-cleared sleep test, see a Sleep Medicine provider, and begin personalized care – all from the comfort of their own home.
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.
Review and audit clinical documentation for accuracy, timeliness, and regulatory compliance.
Ensure documentation meets Medicare Conditions of Participation, state regulations, and accreditation standards.
Lead and support Quality Assurance and Performance Improvement initiatives, tracking key clinical and operational indicators.
They are fixing US healthcare by building an AI-native physical care platform, starting with home health. The company is automating administrative work with AI to create a fundamentally different cost structure than incumbents, enabling them to serve more patients.