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.
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.
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.
Serve as a key subject matter expert on Medicare, Medicaid, and drug pricing policy issues impacting the pharmaceutical/biotech, health insurance, pharmacy, and PBM industries.
Generate strategic and tactical recommendations for clients that are responsive to their policy and business needs.
Oversee multiple complex engagements at a time from proposal development through delivery.
Avalere Health strives to ensure every patient is identified, treated, supported, and cared for equally. They bring Advisory, Medical, and Marketing teams together to forge unconventional connections, building a future where healthcare is not a barrier.
Supports Medical Policy Directors (MPD) through various aspects of the New Policy processes.
Performs multi-faceted data and report analytics to provide accurate client or policy information.
Researches and examines client questions and drafts accurate responses.
Cotiviti provides payment accuracy and analytics-driven healthcare solutions. They have a large team, and cultivate an inclusive and equitable environment for all employees.
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.
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.
Design, deliver, and continuously improve training programs.
Equip staff with the knowledge, tools, and confidence needed to perform.
Support new-hire onboarding, skill development, and regulatory compliance training.
Evry Health is a next-generation health plan built on the belief that healthcare should be simple, transparent, and centered around the member. Their team is mission-driven, collaborative, and committed to removing the complexity that too often stands between people and the care they need.
Assist Area Directors develop their skills while building one-on-one relationships with them.
Train Area Directors in our processes and procedures via phone conferences.
Respond to questions, concerns, and complaints via phone and email with both Area Directors and their advertising clients.
The N2 Company is America’s leading publisher of community magazines. They are proud to provide supportive and fulfilling remote work opportunities for their people in a culture built on trust, respect, and humility.
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.
Own the end-to-end new hire onboarding experience for assigned operations teams.
Design and facilitate ongoing refresher, upskilling, and process change training as business needs evolve.
Build and maintain all training materials for assigned teams.
Sidecar Health is redefining health insurance with a mission to make excellent healthcare affordable and accessible. The team consists of passionate people from diverse backgrounds, united by the desire to fix a broken system.
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.
Communicating with providers regarding claims, service issues and general network provider complaints.
Developing an adequate provider network in assigned geographical areas (currently Texas metroplex areas).
Building and maintaining relationships with contracted providers, including inquiries related to contract status, roster corrections and information accuracy.
Evry Health, a Globe Life company, aims to bring humanity to health insurance. They are a high-technology health plan expanding benefits and access, and feature a personalized, human approach. Globe Life has 16.8 million policies in force, with more than 3,000 corporate employees and 15,000 agents.
Accountable for driving market-wide quality and savings targets by supporting the development of strategies and overseeing the execution of core ACO transformation strategies.
Lead a team of Practice Transformation Specialists (PTS) to ensure high-quality service delivery within the Explorer Market.
Provide frontline feedback to the Program Director to help build and refine the service delivery model while standing up the program.
Aledade empowers independent primary care practices to deliver better 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.
Own and evolve the operating model for Maven’s Client Support function.
Lead and develop a team of Client Support Associates.
Bring the operational perspective into Product and Engineering conversations.
Maven Clinic is the world's largest virtual clinic for women and families, aiming to make healthcare work for everyone. They provide clinical, emotional, and financial support through a digital platform, trusted by over 2,000 employers and health plans, and they have an award-winning culture.
Support medical policy functions by providing medical coding and system configuration support.
Perform coding analyses and utilization reporting to recommend medical policy updates.
Participate in cross-functional meetings to align with enterprise strategic priorities.
Wellmark is a mutual insurance company owned by policy holders across Iowa and South Dakota, built on over 80 years of trust. Motivated by the well-being of members, they are committed to service, sustainability and innovation.
Serve as embedded regulatory thought partner to Clinical and Operations teams, providing real-time guidance.
Partner with Clinical and Compliance team on policy development, audit response, and remediation strategies.
Translate complex healthcare regulations into practical guidance and tools.
Headway is building a new mental healthcare system everyone can access by solving the biggest barrier to care: insurance. They have over 75,000 providers across all 50 states run their practice on their software, serving over 1 million patients.
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.
Meet client needs by collaborating across business functions and following through on outstanding items.
Track internal performance to confirm client expectations are consistently met while maintaining accurate client records.
Research issues, access necessary resources, and escalate to appropriate internal experts for comprehensive resolution.
Personify Health created a personalized health platform, bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together. Our team is on a mission to empower people to lead healthier lives.
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.
Coordinate responses to service escalations, including investigation and documentation.
Perform root cause analysis of service escalations to identify improvement opportunities.
Assist in identifying and developing Operations Reporting and Underwriting manuals.
Fetch is dedicated to helping pets live their healthiest and happiest lives through comprehensive insurance coverage. They are a high-growth Warburg Pincus portfolio company with over 350 pet-loving employees shaping the future of pet health and wellness.