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Investigate, document, track, and assist with claims resolution. Interact with various operational departments to assure accurate and timely payment of claims in accordance with the plan’s policies and procedures. Identify system changes impacting claims processing and work internally on resolution. Identify systematic issues and trends and research for potential co
Posted 1 day ago
Performs and guides others through the business requirements gathering process Analyzes benchmarking data, reports, processes, and measurements Develops and documents business, analysis and reporting requirements Translate business requirements into product specific designs and configuration, detailed requirement specifications and use cases Coordinates a variety of proje
Posted 1 day ago
Contributes/delivers process improvement projects that deliver measurable cost savings, improved quality, increased revenue and growth, productivity, risk avoidance, or overall performance results. Evaluate current business processes and recommend solutions for improvements. Support the development of business cases through analytics Identifies and defines initiatives for
Posted 2 days ago
Analyzes financial, statistical and mathematical data and performs actuarial calculations. Assists in the rate development through analyses of benefit design, rating factors, claims experience, regulatory mandates, admin allocation, and projection of future claim cost. Assists in regulatory rate filings, and prepares data or response for additional inquiries. Assists in t
Posted 3 days ago
Analyzes financial, statistical and mathematical data and performs actuarial calculations. Develops premium rates through analyses of benefit design, rating factors, claims experience, regulatory mandates, admin expense allocation, and projection of future claim cost. Prepares regulatory rate filings, and data or response for additional inquiries. Develops monthly IBNR re
Posted 3 days ago
Thoroughly researches objective scientific evidence and professional guidelines for applicable services. Partners with the Director, clinical team, and subject matter experts (SME's) to evaluate, update, and operationalize clinical review criteria. Clearly documents clinical decisions (and clinical rationales) during the medical policy review process for established clini
Posted 4 days ago
Prioritizes incoming Prior Authorization requests. Processes incoming requests, including authorizing specified services, as outlined in departmental policies, procedures, and workflow guidelines. Refers authorization requests that require clinical judgment to Prior Authorization Clinician, Manager, or Medical Director. Meets or exceeds position metrics and Turn Around Ti
Posted 4 days ago
Performs a variety of diverse and complex telephonic care management responsibilities and ensures that all service needs are met through monitoring of treatment plans, crisis plans, and interagency collaboration Manage and carry out all activities of the Care Management Program. This includes accepting referrals, identifying appropriate care management candidates, ensurin
Posted 4 days ago
Marketing Operations Specialist The Marketing Operations specialist is a key contributor to the success of the overall marketing team, managing key aspects of the marketing process to ensure our vendor partners are effectively managed, our members are provided with their benefits and our marketing campaigns are successfully executed. Reporting to the Manager of Marketing
Posted 4 days ago
Reviews cases referred by the prior authorization non clinical staff according to member benefits, provider availability, and pre determined medical necessity criteria. Clearly and succinctly presents cases to ensure quality care while advocating for appropriate utilization of health system resources (e.g. site of service, level of care, length of stay, etc) consistent wi
Posted 4 days ago
Demonstrates expert knowledge and understanding of BMCHP and Well Sense TPL policies/procedures, MA Subrogation Laws, NH Subrogation Laws, subject expert on processing TPL claims, processing system issue and OPL Application system Serves as a subject matter expert and first line for escalated subrogation issues with attorneys in the day to day operations of the department
Posted 4 days ago
Under the direction of the Manager of OCA Operations, the OCA Program Manager is responsible as the service delivery manager for suppliers, supports Office of Clinical Affairs (OCA) performance, operations, and process improvement, and maintains accountability for projects and initiatives requiring engagement across multiple departments within OCA. Key Functions/Responsib
Posted 4 days ago
Analyzes financial, statistical and mathematical data and performs actuarial calculations. Assists in the rate development through analyses of benefit design, rating factors, claims experience, regulatory mandates, admin allocation, and projection of future claim cost. Assists in regulatory rate filings, and prepares data or response for additional inquiries. Assists in t
Posted 4 days ago
Reviews cases referred by the prior authorization non clinical staff according to member benefits, provider availability, and pre determined medical necessity criteria. Clearly and succinctly presents cases to ensure quality care while advocating for appropriate utilization of health system resources (e.g. site of service, level of care, length of stay, etc) consistent wi
Posted 4 days ago
The Health Data Analyst is a key member of the Clinical Analytics and serves as a strategic partner to various functional areas throughout the organization to meet corporate objectives. Under the leadership and guidance of Director of Clinical and Payment Analytics, the analyst will mainly focus on building strong Utilization Management (UM) operational analytics roadmap.
Posted 5 days ago
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