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• Responsible for planning and executing quality and oversight activities to ensure operational compliance.
• Responsible for internal and external case audits for Capital and our delegated UM vendors.
• Responsible for educating staff on findings, and the audit tool ensuring a consistent approach.

Capital Blue Cross promises to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

• Lead, coach, and mentor a team of Customer Operations Specialists to meet and exceed performance expectations.
• Monitor daily workflows and queues to ensure timely, accurate resolution of provider and client inquiries.
• Track and analyze team performance against key metrics, including OKRs and productivity KPIs.

Grow Therapy is a technology-powered marketplace that empowers therapists, augments insurance payors, and serves patients in need of mental healthcare. They have raised more than $178mm of funding and have empowered more than ten thousand therapists and hundreds of thousands of clients across the country.

• Oversee daily claim workflows ensuring accuracy, timeliness and adherence to compliance requirements within Required SLAs.
• Own team performance across CSAT, Quality, Productivity, Aging, and SLA, translating results into clear action plans.
• Coach and develop team members through 1:1s, performance management and targeted development plans.

Extend is revolutionizing the post-purchase experience for retailers and their customers by providing merchants with AI-driven solutions. Extend works with more than 1,000 leading merchant partners across industries and our headquarters is in downtown San Francisco.

• Leading the Personal Support and Nursing Management team.
• Providing professional knowledge and support to the team.
• Supporting daily operations of client services, case management, and human resources.

CarePartners is one of Ontario’s largest accredited home health care providers, providing nursing, personal support, therapy and rehabilitation support services for patients of all ages. They care for approximately 72,000 patients each year in homes, schools, clinics, workplaces and retirement homes, through their 24 locations and 24 nursing clinics.

• Researches requests for review of resolvable claims from providers.
• Compiles information related to member appeals that request an Executive Review.
• Provides copies of necessary documents and submits information to the Appeals and Policy Manager for review.

PEHP Health & Benefits is a division of the Utah Retirement Systems that serves Utah’s public employees through competitively priced medical, dental, life, and long-term disability insurance plans on a self-funded basis. They embrace both a public mission and a commitment to creating customer value.

• Responsible for ensuring that the Value Hub adheres to regulatory standards, contract requirements, and internal quality benchmarks.
• Analyzing compliance data, preparing detailed reports, and working closely with various departments to maintain and improve compliance and quality standards.
• Supporting the understanding of local regulatory requirements, completion of local audits, participation in quality committees, and supporting health plan needs and interactions to ensure consistent implementation of contractual obligations.

CommonSpirit Health has more than 700 care sites across the U.S. from clinics and hospitals to home-based care and virtual care services. They are committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside their hospitals and out in the community.

• Oversees four teams, leading, supporting, and developing them to succeed.
• Ensures operational excellence through consistent processes, reporting, and communication.
• Drives performance, quality, and continuous improvement across all teams.

BlueCross BlueShield of Tennessee has been helping Tennesseans find their own unique paths to good health since 1945. They empower their employees to thrive both independently and collaboratively, creating a collective impact on the lives of their members.

• Own and execute all CMS Section 111 (MSP) mandatory insurer reporting obligations.
• Manage RxDC (Prescription Drug and Health Care Spending) reporting under the Consolidated Appropriations Act (CAA).
• Serve as the internal SME on No Surprises Act (NSA) compliance, including Good Faith Estimate (GFE) requirements.

Centivo is an innovative health plan for self-funded employers with a mission to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills. Centivo works with employers ranging in size from 51 employees to Fortune 500 companies and is headquartered in Buffalo, NY. They value being resilient, uncommon, and positive.

• Establish and monitor performance metrics to measure the reliability and latency of payer data feeds.
• Serve as the primary point of escalation for high-priority payer data issues, coordinating with various teams.
• Oversee the documentation and submission processes for clinical data extracts to ensure audit readiness.

Aledade empowers independent primary care practices to deliver better patient care and thrive in value-based care. As the largest network of independent primary care in the country, they focus on creating value-based contracts, strengthening care continuity, and aligning incentives to ensure physicians are paid for keeping patients healthy.

• Review all assigned OASIS assessments for accuracy, completeness, and consistency.
• Validate diagnosis coding and sequencing per CMS guidelines.
• Identify and correct errors impacting reimbursement, quality measures, or compliance.

They are responsible for coding, reviewing, validating, and correcting OASIS assessments to ensure clinical accuracy, regulatory compliance, and optimal reimbursement. This is an adaptive, remote-friendly role designed to scale with agency census and workflow needs.

• Deliver compassionate, personalized service to support each member’s unique therapy journey.
• Manage new and ongoing therapy cases, ensuring accurate documentation and coordination.
• Resolve inquiries quickly and accurately, using critical thinking to address complex issues.

VIVIO Health helps make data the basis for clinical decision-making. Their evidence-based, data-driven specialty drug management and cost control solution has improved healthcare outcomes and lowered costs for large, self-insured employers since 2016.

• Complete timely review of healthcare services using appropriate medical criteria to support determinations.
• Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards, and Guidehealth policies.
• Communicate precertification and concurrent review decisions—verbally and in writing—to required parties within defined timeframes.

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. They aim to make great healthcare affordable, improve patient health, and restore fulfillment in practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages Healthguides™ and a Managed Service Organization to build stronger connections with patients and providers.

• Lead end-to-end investigations into compliance and ethics.
• Translate complex regulations into practical guidance.
• Identify systemic risks and ensure robust remediation.

Rula is dedicated to treating the whole person and aims to create a world where mental health is embraced as an integral part of one's overall well-being. They are a remote-first company that is dedicated to having a culture of inclusion that will support their employees.

• Monitor federal and state laws impacting government programs.
• Provide cross-functional guidance for compliance with legal requirements.
• Coordinate and support compliance audits, ensuring timely responses.

CareCentrix is focused on healthcare at home, aiming to simplify care delivery and management. They offer services like home health, durable medical equipment, and home infusion, managing care for over 19 million members across the U.S. and Puerto Rico.

• The Case Manager is a key member of the interdisciplinary care team (ICT).
• They use a collaborative process of assessment, planning, coordinating, and monitoring to meet members' health and social needs.
• They act as a liaison between Members, their Responsible Parties, the Advance Plan Provider/PCP, and key stakeholders.

Curana Health aims to radically improve the health, happiness, and dignity of older adults. They are a national leader in value-based care, serving 200,000+ seniors in 1,500+ communities across 32 states with a team of more than 1,000 clinicians alongside care coordinators, analysts, operators, and professionals from all backgrounds.

• Own the execution of clinician chart audits and watchlist tracking.
• Investigate clinical incidents, chart audits, and collaborate on root cause documentation.
• Track quality, safety, and clinician performance metrics using manual and automated tools.

Wheel is evolving the traditional care ecosystem by equipping the nation's most innovative companies with a premier platform to deliver high-quality virtual care at scale. They offer proven strategies and cutting-edge technologies to foster consumer engagement, build brand loyalty, and maximize return on investment.

• Assists in the maintenance of structures and processes which support improvement and patient safety.
• Uses clinical knowledge in formal and informal consultation with individual staff, clinicians and managers, to address clinical quality and safety concerns.
• Participates in clinical adverse event task groups.

Dartmouth Health is a nationally recognized Academic Medical Center set in the White Mountains of New Hampshire, stretching over New Hampshire and Vermont. They offer a rigorous, research-focused environment and are anchored by the academic Dartmouth Hitchcock Medical Center in Lebanon, NH.

• Participate in provider case reviews to identify trends and deficits.
• Coach providers and participate in client meetings to support expectations.
• Contribute to workflow design, QA improvements, and risk management.

Amwell transforms healthcare with technology and people. They aim to provide convenient, affordable, and effective care, serving large healthcare organizations in the U.S. and worldwide.

• Monitor doctor performance across the clinic to ensure high clinical and service standards
• Analyse performance data including consultation quality, documentation, utilisation and complaints
• Conduct regular 1:1 performance conversations with doctors, providing coaching and feedback

Montu is Australia's largest healthtech business with a focus on alternative healthcare. Founded in 2019, it supports patients, doctors and pharmacies through its Alternaleaf clinic, offers accredited healthcare education to clinicians via its SAGED platform, and dispensing solutions to pharmacies across Australia through Leafio.

• Demonstrates knowledge of basic audit skills and adheres to Internal Audit Standards and UPH Internal Audit policies and methodologies.

UnityPoint Health is committed to their team members and has been recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare several years in a row. They champion a culture of belonging where everyone feels valued and respected, and believe in equipping you with support and development opportunities to deliver an exceptional employment experience.