Responsible for supporting the implementation, maintenance, analysis, and quality assurance of ConnectiveRx pharmaceutical affordability programs.
Accountable for program set-ups and maintenance, performs quality control on program setups and updates, and investigates adjudication outcomes and data discrepancies.
Applies business rules consistently to ensure operational accuracy and program integrity and works independently on routine tasks.
Analyzes and answers inquiries regarding pharmacy claims adjudication.
Adjudicates pharmacy claims and processes pharmacy claims for payment.
Performs varied activities and moderately complex administrative/operational/customer support assignments.
Humana is committed to helping people live healthy lives, creating personalized experiences, and working collaboratively. They offer medical, dental, and vision benefits, a 401(k) retirement savings plan, and paid time off.
Interpret medical rules, regulations, fee schedules, and edits that payers post.
Understand and manipulate payer data to build federal, state, and commercial coding and financial tables.
Maximize the efficiency and use of product solutions by properly maintaining payer specific edits.
Experian is a global data and technology company, powering opportunities for people and businesses around the world. They operate across a range of markets and have an amazing team of 25,200 people in 32 countries.
Supports outbound calls and data/benefit analysis related to various clinical pharmacy programs.
Performs advanced administrative/operational/member support duties.
Initiates and responds professionally to a high volume of calls in a timely and efficient manner.
Capital Blue Cross promises to go the extra mile for their team and community. It appears to be a large company, that values its employees, as they are consistently voted one of the “Best Places to Work in PA”.
Actively engages with Benefits Administration system to complete new and renewing account installation.
Provides assistance to internal and external clients with basic BenAdmin Q&A, reports, troubleshooting and data questions.
Consistently achieves or exceeds established SLA expectations on individual performance.
CRC Benefits is an industry leading provider of benefits services, with a culture focused on inclusion, trust, collaboration, and innovation. The company has earned a Top Workplaces USA award three years in a row based solely on employee feedback, valuing employees and encouraging growth.
Serve as the primary contact for CM/UM programs and operational questions related to the MyCare Platform.
Build relationships with provider offices through outreach and timely follow-up, resolving issues within defined turnaround times.
Educate providers on submission requirements, documentation, timelines, and available CM/UM resources.
Personify Health created a personalized health platform, bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together. They serve employers, health plans, and health systems with data-driven solutions that reduce costs while improving health outcomes.
Answer new referral intake and refill calls in a timely and professional manner, accurately updating information in the computer system.
Contact patients to collect necessary information for their medical chart, schedule deliveries for refills, and set up shipping arrangements as needed.
Work cooperatively with all departments to maintain accurate patient records, exemplify excellent customer service, and participate in training programs and meetings.
VytlOne is transforming the pharmacy industry to create healthier lives through services across Pharmacy Benefit Management, Pharmacy Management, Specialty Pharmacy, 340B, Rebate and Formulary Management, and Pharmacies. The company fosters a diverse, progressive, and team-oriented culture that promotes a work-from-home model and innovation.
Oversee prior authorization technicians and administrative PA functions.
Analyze data and provide staffing, workflow, and system enhancement recommendations.
Investigate/resolve escalated issues from clients and providers.
Judi Health is an enterprise health technology company providing a suite of solutions for employers and health plans. They have a comprehensive Enterprise Health Platform that consolidates all claim administration-related workflows in one scalable, secure platform.
Manage complex provider roster creation, submission, and record reconciliation for multiple payers.
Oversee resolution of moderate-scope issues by prioritizing tasks and escalating issues with solutions.
Proactively identify areas for operational improvement and efficiency enhancement.
Aledade empowers independent primary care practices to deliver better patient care and thrive in value-based care. Founded in 2014, they are the largest network of independent primary care in the country with a collaborative, inclusive, and remote-first culture.
Maintain, update, and manage employee enrollment and eligibility files with accuracy and timeliness.
Process and track eligibility changes, including new enrollments, terminations, qualifying events, and status updates.
Communicate professionally with internal departments, vendors, and clients to resolve billing and eligibility issues.
Trucordia is an insurance brokerage that offers an unrivaled combination of people, tools, and solutions. The company has more than 5,000 team members across 200 offices and is ranked as one of the fastest-growing companies in the U.S.
Directly lead and manage a team of Patient Support Associates to ensure medication adherence or timely prior authorization.
Proactively manage support in assigned hospitals and/or clinics to ensure patients receive medications on-time.
Provide front-line supervision and ongoing coaching and performance management to Patient Support team.
Shields Health Solutions is a specialty pharmacy management service provider. They are a fast-growing company that values motivated self-starters with a positive outlook and a focus on high-quality work.
Conduct high-volume calls with patients, providers, and pharmacies using established protocols.
Collaborate with patients to remove barriers to medication adherence and escalate clinical barriers to a pharmacist.
Accurately document all interactions, outcomes, and identified barriers in appropriate systems.
Aledade empowers independent primary care practices to deliver better care and thrive in value-based care. Founded in 2014, they've become the largest network of independent primary care in the country with a collaborative, inclusive, and remote-first culture.
Responsible for the review and processing of claims within the claims transactional system, according to plan benefits and contractual reimbursement terms.
Follows established policies and procedures to pay, pend for additional information, or deny claims.
Accountable to meet and maintain established department production and quality standards.
Evry Health is on a mission to bring humanity to health insurance by expanding benefits, increasing access and transparency, and featuring a personalized, human approach. Evry Health is the major medical division of Globe Life (NYSE:GL) with more than 3,000 corporate employees and 15,000 agents.
Execute data analysis of trends and strategic opportunities for quality improvement across Affordability Initiatives portfolio.
Track project milestones, timelines, and deliverables from live and asynchronous engagements - ensuring alignment with initiative-specific program goals.
Maintain and provide consistent tracking of KPIs and other performance metrics to enable measurement of programs and project outcomes
Aledade empowers the most transformational part of our health care landscape - independent primary care. Since being founded in 2014, Aledade has become the largest network of independent primary care in the country, helping practices, health centers and clinics deliver better care to their patients and thrive in value-based care. They foster a collaborative, inclusive and remote-first culture.
Review and process patients’ enrollment forms for the Patient Assistance Program.
Assist patients on the phone with PAP program enrollment by verifying pre-screening and qualifying tasks.
Notify patients and healthcare providers of approvals, denials, and any next steps needed to continue the enrollment process.
CareTria aims to help patients access coverage for their prescribed medications. We provide telephone support and administrative functions. The company offers comprehensive benefits and is an Equal Opportunity Employer, indicating a commitment to a positive and inclusive work environment.
Provide proactive account management including helping entities manage a compliant 340B program, owning and building relationships with managed accounts.
Develop a communication plan with the client that promotes awareness about products, tools, interfaces, modules, and services.
Ensure customer expectations are met by maintaining open, clear, and consistent dialogue with external end-users and internal contacts.
VytlOne provides services and technology that fuel the entire pharmacy ecosystem, enabling pharmacy care. They're a company of 1,000 diverse people with almost 100 years of pharmacy experience, offering the stability of a Fortune 500 company with the energy and innovation of a startup.
Deliver an outstanding customer experience by supporting inquiries across phone, email, text, and chat.
Manage high-complexity insurance workflows and inbound support requests to collect documentation.
Partner with clinical, scheduling, and operations teams to ensure accurate treatment plan alignment and continuity of care.
Expressable is a virtual speech therapy practice that aims to transform care delivery and expand access to high-quality services. Since 2019, they serve thousands of clients with a focus on parent-focused intervention and an e-learning platform with home-based learning modules.
Responsible for processing insurance claims accurately and efficiently.
Analyze claim data to identify trends, errors, and potential irregularities.
Serve as a liaison between departments to support seamless claims resolution and continuous process improvement.
Curana Health is dedicated to radically improving the health, happiness, and dignity of older adults. They are a fast-growing company serving over 200,000 seniors in 1,500+ communities across 32 states.
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.
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.
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.