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Position Purpose: Develops, assesses, and coordinates care management activities based on member needs to provide quality, cost-effective healthcare outcomes. Develops or contributes to the development of a personalized care plan/service plan for members and educates members and their families/careg

Position Purpose: Convert analytics business requirements into technical requirements and implemented projects through working with IT, business, and analytics partners. May source data directly via batch and pipeline processes and manage SDLC processes. Key Details: This remote role provides a full

Position Purpose: Support the development and maintenance of Risk Adjustment related programs and reporting. Aid in working with Risk Adjustment vendors for programs within all lines of business. Key Details: RN License, Clinical and/or Quality Improvement and HEDIS experience is required. Candidate

Position Purpose: Responsible for advanced and predictive data analytics using big data and data science technology for healthcare innovation. Perform analysis using data science techniques on structured and unstructured data sets, and develop algorithms for targeted business needs. Key Details: Mus

Position Purpose: Generates, processes and maintains provider and member correspondence for preservice and concurrent review. Key Details: Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not av

Position Purpose: Responsible for advanced and predictive data analytics using big data and data science technology for healthcare innovation and outcomes. Perform analysis using data science techniques on structured and unstructured data sets, and develop algorithms for targeted business needs. Key

Position Purpose: Act as the liaison for all statewide appeals, fair hearings, review organizations, and other external type appeals. Responsible for ensuring that all appeal letters generated comply with both State and NCQA requirements. Key Details: This is a remote position. Hours are Monday-Frid

Position Purpose: Assists in developing, assessing, and coordinating holistic care management activities to enable quality, cost-effective healthcare outcomes. May develop or assist with developing personalized service care plans/service plans for long-term care members and educates members and thei

Position Purpose: Develops, assesses, and coordinates care management activities based on member needs to provide quality, cost-effective healthcare outcomes. Develops or contributes to the development of a personalized care plan/service plan for members and educates members and their families/careg

Position Purpose: Completes Qualified Health Plans (QHP) federal and/or state required application templates and documents for low, medium and high risk states, including policy forms for individual commercial marketplace products. Reviews and provides interpretation of application instructions from

Position Purpose: Manage assigned functional area (filing submissions; state legislative/regulatory interpretation and policy research; development of member materials or QHP templates, and/or product benefit database). Responsible for quality of their functional area outputs. Regulatory oversight a

Position Purpose: Develops, assesses, and facilitates complex care management activities for primarily physical needs members to provide high quality, cost-effective healthcare outcomes including personalized care plans and education for members and their families. Key Details: This remote position

Position Purpose: Supports care management activities and the teams assigned to members to ensure services are delivered by the healthcare providers and partners and continuity of care/member satisfaction is achieved. Interacts with members by performing member outreach telephonically or through hom

Position Purpose: Develops, assesses, and facilitates complex care management activities for primarily mental and behavioral health needs members to provide high quality, cost-effective healthcare outcomes including personalized care plans and education for members and their families related to ment

Position Purpose: Acts as a resource and supports the prior authorization request process to ensure that all authorization requests are addressed properly in the contractual timeline. Supports utilization management team to document authorization requests and obtain accurate and timely documentation

Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT. Position Purpose: Analyze

Position Purpose: Provides support with identifying, overseeing, and managing the coordination of transition of members in the community. Works with leadership to ensure the timely and safe transition of members in the community from various levels of health care services including coordinating care

Position Purpose: Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote qu

Position Purpose:Supports the goals and outcomes of the organization by leading the transformation of our business strategy. Ensures deliverables are met, by assisting with design, execution, and value estimation and realization for initiatives. Partner with business leaders to identify opportunitie

Position Purpose: Work with the Pharmacists to accurately assist prescription orders in a timely manner Key Job Details: Pharmacy Technician II (Onsite Specialty Outreach - Customer Service - Phone Outreach with Data Entry) - Houston, TX. This onsite Licensed Pharmacy Technician II role is located a