Contribute and oversee strategic projects, ETL design and architecture, performance tuning activities, Code Reviews, and Best Practices Responsible for approving and certifying the architecture and design of the data warehouse, data marts and BI reports which will support various data initiatives Supervision of development of ETL code with our current toolset, Informatica

Receive assigned provider inquiries and perform a code review on both professional and facility claims Make determinations on cases after a coding review is complete Review various edits on cases and complete audit of medical records received to ensure proper editing is applied Review medical charts electronically Abstract and code diagnosis and procedures from the medica

Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medicati

Primary focus will be on a Local Market book of business Intricate focus on product integration to maximize company financials Work closely with underwriting and local market sales to derive competitive financial responses Meets quarterly reporting requirements Anticipates customer needs and proactively develops solutions to meet them Serves as a key resource on complex a

Perform telephonic outreach to improve health quality outcomes Optimize pharmacy therapy through additional telephonic engagement with providers and pharmacies Oversee pharmacy projects from inception to completion Provide responses to drug information requests Assess and interpret customer needs and requirements Identify solutions to non standard requests and problems Co

Review, validate and maintain financial and other records as they relate to client specific programs for Taft Hartley Fund Responsible for timely reconciliation of all accounts Process payments and retrieve required statements from websites Communicate financial discrepancies and resolve Responsible for all financial exchanges related to participant accounts Identify erro

Investigate medium to highly complex cases of fraud, waste and abuse Detect fraudulent activity by members, providers, employees and other parties against the Company Develop and deploy the most effective and efficient investigative strategy for each investigation Maintain accurate, current and thorough case information in the Special Investigations Unit's (SIU's) case tr

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, least restrictive level of care Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact Com

Key Agent/Agency Performance Agent Development Mentor, coach and engage key agents/agencies through ongoing business and strategy planning. This includes identifying sales opportunities, product positioning, UHC tools, UHC value proposition, compliance, and market education Onboarding Reach out to new agents identified by the PHD to share UHC learning, growth tools and va

Coach and motivate agents to achieve or exceed sales targets with a focus on quality and compliance Supervise the daily activities of the team by reviewing and analyzing calls / reports, assessing areas of opportunity, managing work assignments and assuring agents are providing a positive consumer experience Develop staff by providing one on one coaching, conducting role

Provide an exceptional customer service experience when responding to and resolving customer service inquires and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility and claims, financial spending accounts and correspondence Research complex issues (such as Medical, Dental, Flex Spending, Pharmacy, etc.) across multiple da

Answer incoming phone calls from customers and identify the type of assistance the customer needs (i.e. benefit and eligibility, billing and payments, authorizations for treatment and explanation of benefits (EOBs) Ask appropriate questions and listen actively to identify specific questions or issues while documenting required information in computer systems Own problem t

Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medicati

Answer incoming phone calls from prospective members, identify the type of assistance and information the customer needs with the goal to convert caller to a qualified lead and sale Follow up with members on questions or to review current or new products and services Navigate multiple computer systems to document member information while maintaining active listening and e

Answer incoming phone calls from prospective members, identify the type of assistance and information the customer needs with the goal to convert caller to a qualified lead and sale Follow up with members on questions or to review current or new products and services Navigate multiple computer systems to document member information while maintaining active listening and e