EmblemHealth Jobs

Responsible for the execution of the non-clinical aspects of the Utilization Management process. Ensure information is appropriately entered in the system to effectively execute member care plans, originate authorizations, request clinical information, perform case research, and essentially execute all behind the scenes desk-level procedures of a case. Work seamlessly with other interdisciplinary teams to ensure members' needs are met. Provide confidential administrative support and assistance to the department in all aspects of daily program operations. Principal Accountabilities Work collaboratively, as a critical component of the Medical Management team, to facilitate all clerical and administrative processes and activities. Perform accurate and timely intake and data entry for all UM authorization requests and referrals for all lines of business, upon receipt of inbound utilization management requests, via call, fax and web portal, in accordance with departmental policy and regulatory requirements. Triage cases and assign receipts to appropriate teams. Respond to inquiries from providers, facilities and members. Initiate completion of member and provider correspondence and verbal outreach according to departmental guidelines. Enter and maintain documentation in the medical management workflow tool, meeting defined timeframes and performance standards. Provide phone management for both incoming and outgoing calls. Communicate with members and providers as required. Perform other related projects and duties as assigned. Adhere to processes for collecting member-specific clinical and demographic data from providers and other entities as required by clinical staff. Support communication and coordination with delegated entities, as necessary. Actively participate in assigned committees and projects. Qualifications High School Diploma required Associates degree or Bachelor's degree in related field preferred At least 1-2 years of previous client-facing or data entry experience in a health care environment Additional years of experience/certifications/training may be considered in lieu of educational requirements Strong communication skills (verbal, written and interpersonal) Ability to work both independently and collaboratively with others Previous system user experience in a highly electronic environment Proficient in MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.) Knowledge of medical terminology and medical payment Ability to prioritize multiple tasks Ability and willingness to work weekends and holidays as necessary Additional Information

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. We are currently seeking an Inpatient Care Management Medical Director to join our Optum team. This team is responsible for conducting acute level of care and length of stay reviews for medical necessity for our members being managed within the continuum of care. Our clients include local and national commercial employer, Medicare, and state Medicaid plans. The Medical Directors work with groups of nurses and support staff to manage inpatient care utilization at a hospital, market, regional or national level. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: Participate in telephonic outreach for collaboration with treating providers. This will include discussion of evidence - based guidelines, opportunities to close clinical quality / service gaps, and care plan changes that can impact health care expenses Responsible to collaborate with operational and business partners on clinical and quality initiatives at the site and customer level to address customer expectations Is grounded in the use and application of evidence-based medicine (EBM) such as InterQual care guidelines and criteria review Occasionally, may participate in periodic market oversight meetings with the outward facing Chief Medical Officers, network contractors, nurse management and other internal managers Maintain proficiency in all required software and platforms Although the United Health Services ICM Medical Director's work is typically concentrated in a region, they are part of a national organization and team, and collaborate with peers, nurse managers, and non-clinical employees from across the country. In response to customer needs and expectations, Optum is continuously modifying its programs and approaches. Although not a primary job function, Medical Directors with the interest in doing so often can be involved with change design and management. You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: MD or DO with an active, unrestricted medical license Current Board Certification in an ABMS or AOBMS specialty 3+ years of clinical practice experience post residency Private home office and access to high-speed Internet Technical proficiency in computer software and systems Preferred Qualifications: Licensure in either HI, AK, OR, ID, WA, UT a plus 2+ years of managed care, Quality Management experience and/or administrative leadership experience Prior UM experience Clinical experience within the past 2 years *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.

Summary of Job Analyze, review, and process suspended claims, predetermination, and Service Requests based on industry standards and clinical guidelines. Research, analyze, and investigate member benefits, policy and procedures for claims, grievance and appeal cases. Provide provider outreach where necessary to facilitate claim resolution and escalated service requests. Obtain claim records and supporting documentation needed for resolution. Collaborate with Dental Consultants to review and triage escalated claims, pre-determinations, and service requests. Integrate clinical expertise with industry knowledge to identify potential fraud patterns upon claim submission, alerting dental director, and SIU team when applicable. Responsibilities * Review and analyze claims and pre-determinations within suspended system inventory using clinical expertise, industry standard guidelines, and benefit policy and procedures and make changes to procedure codes when necessary, using-supporting documentation (including radiographs, charting, correspondence) for payment or denial. * Perform provider outreach when applicable for resolution. * Investigate member benefits, policy and procedures for claims, grievance and appeal cases, and member and provider outreach via customer service and dental network team. * Utilize specialized knowledge to analyze and resolve issues with dental claim coding. * Initiate down-coding of submitted procedure codes that do not meet standards of care and/or the supporting documentation submitted with claim. Refer clinical denials to consultant for review with all necessary support information when needed. * Identify potential claims problems or fraud patterns and refer to Lead analyst, Dental Director and SIU when necessary. * Identify the need for new messages to clarify the Explanation of Benefits; contribute to/develop message changes. * Recommend methods to improve the dental logic to boost system efficiency to Dental Director. Qualifications * Bachelor's Degree (Preferred) * Certification as Dental Hygienist or Claims Coding (Required) * 2 -3+ years of related experience, including experience in a clinical dental environment (Required) * Additional experience/specialized training/certifications may be considered in lieu of Bachelor's degree (Required) * Knowledge of claim processing policies and procedures (Required) * Proficient with MS Office - Word, Excel, PowerPoint, Outlook, Teams, etc. (Required) * Strong communication skills - verbal, written, presentation, interpersonal (Required) * Demonstrated analytical and problem-solving skills (Required) Additional Information * Requisition ID: 1000002532 * Hiring Range: $48,600-$83,160

Summary of Job Serve as advisor on health equity, SDOH, and population health programming, collaborating with a wide range of internal and external stakeholders, responsible for EmblemHealth's strategy and mission. Develop and lead programs with focus on improved health outcomes of groups across the community; monitor and identify individual patients within that group based on medical conditions, age, and location. Use data to ensure an equal distribution of health resources among all members of our insured community. Oversee quality improvement to improve care, reduce costs, and deliver evidence-based outcomes. Responsibilities * Participate and lead the development, performance, and maturation of existing programs. * Provide subject matter expertise in areas such as health equity analytics, community health, bias reduction, and diversity equity and inclusion. * Lead and/or serve on a variety of appropriate internal and external committees to represent Population Health. * Review and analyze population and patient data related to clinical care and outcomes to evaluate performance, reveal trends and identify opportunities. * Collaborate with internal and external organizations to execute innovative programs and build partnerships. * Drive change management to balance community needs with government system changes. * Lead the population health strategy and NCQA's Population Health Management program. * Collaborate with clinical, operations, and community teams to enhance the patient experience and reduce per member cost. * Identify root causes, analyze data, and develop metrics to reduce health disparities. * Prepare reporting to present findings and highlight successes and opportunities for improvement or intervention. * Engage with diverse communities to set priorities and drive planning efforts. * Monitor performance indicators to ensure exceptional quality outcomes. * Prepare and execute operational plans to achieve measurable objectives on an established timetable. * Develop programs to address barriers to healthcare as determined by patient need. * Assist in applying for and reporting on grant-funded programs. * Actively participate in quality improvement committees, subcommittees and workgroups to support process improvement. * Review and update operational processes for quality management activities. Define and document newly established processes. * Remain current with new trends and best practices and incorporates into Population Health programs. * Support preparation, organization and follow-up in acquiring and maintaining NCQA accreditation and compliance with local, state and federal regulatory authorities, includes support of the health plan's HEDIS, QARR, and Star processes. Qualifications * Bachelor's Degree in a health services field (Required) * Master's degree (Preferred) * 10 - 12+ years of experience in the health care field, preferably in managed care experience (Required) * Ability to work with staff in several locations where the company has offices, necessitating site visits * Proficient in Microsoft Office - Word, PowerPoint and Excel, Access (Required) * Proficient in data analysis. Strong working knowledge of relational database and statistical analyses (Required) * Must be familiar with and have a strong knowledge of QI process improvement methodology strategies, including but not * limited to PDSA and DMAIC (Required) * Must be familiar with the HEDIS, QARR, CAHPS and HOS requirements (Required) * Must possess analytical skills to collect, organize and present data in a clear and concise manner (Required) * Ability to assess all work and prioritize as necessary to meet reporting timeframes and deadlines (Required) Additional Information * Requisition ID: 1000002409 * Hiring Range: $92,880-$178,200

**Become a part of our caring community and help us put health first** The Associate Actuary, Analytics/Forecasting analyzes and forecasts financial, economic, and other data to provide accurate and timely information for strategic and operational decisions. Establishes metrics, provides data analyses, and works directly to support business intelligence. Evaluates industry, economic, financial, and market trends to forecast the organization's short, medium and long-term financial and competitive position. The Associate Actuary, Analytics/Forecasting work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Associate Actuary, Analytics/Forecasting ensures data integrity by developing and executing necessary processes and controls around the flow of data. Collaborates with stakeholders to understand business needs/issues, troubleshoots problems, conducts root cause analysis, and develops cost effective resolutions for data anomalies. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments. This role is part of the Consumer Growth - Membership Analytics team. As a part of this team, individuals will work closely with the Consumer Growth Strategy Team to guide and evaluate Humana's growth initiatives, particularly around strategies related to segmentation of our members. This role will directly collaborate with various business partners including initiative owners and finance stakeholders. Candidates pursuing this role should be passionate about combining actuarial analytics skills with business knowledge to help our partners devise the best strategies to help Humana grow. This role can work remotely from anywhere in the United States but is expected to work wither Eastern or Central hours. **Use your skills to make an impact** **Required Qualifications** + Bachelor's Degree + Associate of Society of Actuaries (ASA) designation + Meets eligibility requirements for Humana's Actuarial Professional Development Program (APDP) + MAAA + Strong communication skills + Knowledge of medical insurance (preferably Medicare Advantage) **Work-At-Home Information** To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: + At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. + Satellite, cellular and microwave connection can be used only if approved by leadership. + Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. + Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. + Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **Scheduled Weekly Hours** 40 **Pay Range** The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $106,900 - $147,000 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. **Description of Benefits** Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Application Deadline: 06-08-2025 **About us** Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large. **Equal Opportunity Employer** It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our ***************************************************************************

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start **Caring. Connecting. Growing together.** Individual and Family Plans (IFP) is a growing business within UnitedHealthcare. The Coding Consultant for IFP Product provides medical coding expertise to support internal policy development, benefit definition and accurate benefit configuration. They research and interpret healthcare correct coding using regulatory requirements and guidance related to CMS and CPT/AMA, review other major payer policies, and use internal business rules and policies to prepare written documentation in support of benefit configuration. The Coding Consultant for IFP Product possesses an overall understanding of all coding principles, including facility and physician coding and dental coding. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. **Primary Responsibilities:** + Serve as a coding resource and provide coding expertise and guidance for IFP Product and configuration partners + Develop and maintain code sets used to define IFP medical and specialty benefits (hearing, vision, dental), seeking and promoting enterprise alignment when appropriate + In partnership with Product and Clinical partners, ensure IFP sources of truth for benefit administration/configuration (e.g., benefit configuration guidelines, Pay Code Status lists, etc.) contain accurate and complete CPT, HCPCS, Revenue, CDT and/or ICD-10 codes to support benefit intent + Monitor annual and quarterly code updates, identify impacts to IFP Product documentation, and update documentation as needed + Ensure adherence to state and federal policies/mandates, reimbursement policies and contract requirements + Facilitate meetings with key partners, including: Clinical, Operations, Claims, Configuration and others to achieve benefit design coding solutions + Research and interpret correct coding guidelines and internal business rules to respond to benefit inquiries and issues + Identify and recommend opportunities for cost savings and improving outcomes You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. **Required Qualifications:** + 3+ years of medical coding experience in a health insurance product implementation, benefit/coverage policy development, benefit configuration, or claims role + Have and maintain one or more of the following coding credentials: CPC, CCS-P, CCS, CPMA or equivalent + Experience analyzing data and/or regulatory requirements, problem solving, and providing fact-based recommendations or make decisions based on analysis + Experience performing clinical coverage review of post-service (pre-or-post payment) of claims requiring interpretation of state and federal mandates; certificates of coverage, medical and reimbursement policies, coding requirements and consideration of relevant clinical information on claims + Experience multi-tasking, prioritizing, and managing time efficiently across multiple work partners + Knowledge of Commercial medical insurance benefits **Preferred Qualifications:** + Experience with health insurance reimbursement policy + Familiarity of SNOMED, LOINC, NDC and CDT + Experience in the plan build/plan configuration + Proficient in Microsoft Word, Excel, PowerPoint, etc. + Demonstrated ability to work collaboratively and influence others to drive timely decisions + Ability to work independently, or as an active member of a team + Accurate and precise attention to detail + Excellent analytical, verbal and written communication skills *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy The salary range for this role is $89,800 to $176,700 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives. **Application Deadline:** This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. _At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission._ _UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations._ _UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment._

Summary of Job Perform analyses and calculations to produce accurate and timely broker and internal sales reps' commission results. Utilize various systems and data sources to gather, interpret, analyze, and synthesize data for calculations. Ensure brokers are properly licensed and appointed to sell in the NY markets; monitor internal staff that require a valid license. Provide analysis to support compensation business decisions. Support department on special projects/tasks specific to departmental needs. Responsibilities * Ensure accurate and timely monthly broker commission payments: review and maintain Facets commission modules with correct commission plan schedules, group and broker affiliations. * Coordinate with the CTS Broker Operations to team to ensure monthly notifications to the external broker community regarding licensing and NYSOH certifications are sent. * Collaborate with the CTS Broker Operations and CTS IT teams to ensure monthly commissions remain on schedule to meet the department's SLA. * Enroll external brokers in Electronic Funds Transfer via PNC. * Maintain Internal Sales Reps NYS licenses. * Respond to inquiries in a timely manner from internal colleagues and external brokers regarding commission and licensing, or portal questions. * Identify and analyze potential and actual issues and impediments to producing accurate commissions; review processes, procedures, sources, and systems to locate shortcomings; provide recommendations for improvements. * Coordinate resolutions; implement solutions; review results to ensure successful corrections/improvements. * Communicate with new and existing brokers to obtain documents to process broker appointments to ensure brokers are properly licensed and appointed to sell NY products. * Monitor the license and appointment statuses on the NY Dept. of Financial Services website for external brokers. * Review broker affiliation request and forward to the CTS Broker Operations team for processing. * Support daily functions of broker operations. * Perform other tasks as directed or required. Qualifications * Bachelor's Degree * 3 - 5+ years of relevant, professional work experience (Required) * Experience in calculating and processing commission payments (Required) * Additional experience or specialized training may be considered in lieu of educational requirements (Required) * Strong attention to detail; critical thinking, analytical and problem-solving skills (Required) * Proven ability to absorb and interpret information and data, and to convey ideas and concepts to resolve issues (Required) * Strong communication skills - verbal, written, presentation, interpersonal (Required) * Proven ability to meet strict deadlines (Required) * Proficient with MS Office - Word, Excel, Access, Outlook, and information systems/software (Required) Additional Information * Requisition ID: 1000002420 * Hiring Range: $56,160-$99,360

Summary of Job Identify, develop, execute, evaluate and provide oversight of quality and process improvement projects required to support public health, HEDIS, QARR, NCQA and other regulatory quality measures for our network providers that EmblemHealth members receive across the enterprise. Develop and monitor Quality Improvement metrics in collaboration with department leadership to ensure that gains are maintained and corrective actions are taken as necessary to ensure performance improvement and to support compliance with HEDIS, QARR, and Star processes across all regions where we have membership. Drive and monitor clinical performance with vendor activities to support continued improvement in the quality data set. Collaborate with the leadership of Provider Network and Product, Analysts, IT and other cross functional teams to align strategies and quality improvement priorities in contracting, vendor relationships, sales and product development, and procurement. Manage a team of associates to achieve optimized quality and stars ratings from internal stakeholders and network providers. Responsibilities * Support Quality improvement processes for our network providers across all regions where we have members. * Collaborate cross-functionally and with all vendors to define quality and process improvement projects that support corporate initiatives and have a reasonable chance of success with measurable and timely results. * Review and analyze quality-related data to design, develop, monitor, and evaluate clinical and administrative service studies to support quality improvement activities and programs. * Prepare reports, abstracts, and presentations based on the analysis of process/outcome measures of various behavioral health clinical studies and present formal study findings to various committees/groups within the organization as well as at professional conferences. * Manage the Provider Incentive Program (PIP) across the enterprise to drive improved quality performance of network providers. Carry out project plans and roadmaps for provider collaboratives that define the path to specific actions resulting in improved quality performance for Medicare, Medicaid and the Exchange business. Performance improvement includes HEDIS, CAHPS and HOS measures that will improve plan Quality scores. * Define and implement the enterprise strategies to deliver quality excellence, including measurement of each strategy to further refine and improve results. * Manage engagement and Quality education tools for providers and vendors and report on their use and effectiveness. * Develop measurement tools for data collection, metrics to assess the effectiveness of process revisions, and control tools for use in monitoring and sustaining project results. * Ensure that corrective action plans are instituted accordingly across the company. Apply appropriate statistical procedures for the analysis of quantitative and qualitative data and evaluation of clinical and administrative service improvement activities. * Actively participate in selected quality improvement committees, subcommittees and workgroups to support process improvement activities. Review and update operational processes relating to quality management activities. Define and document newly established processes. * Support preparation, organization and follow-up in acquiring and maintaining NCQA accreditation and compliance with local, state and federal regulatory authorities, includes support of the health plan's HEDIS, QARR, and Star processes Qualifications * Bachelor's Degree in a health services field (Required); Advanced degree (Preferred) * Six Sigma Green or Black Belt (Preferred) * 5 - 8+ years' experience in the health care field, preferably in managed care experience (Required) * Ability to work with staff in several locations where the company has offices, necessitating site visits (Required) * Staff/process management experience (Preferred) * Proficient in MS Office - Word, PowerPoint, Excel, Outlook, Teams, SharePoint, etc. (Required) * Proficient in MS Access (Preferred) * Experience with and proficient in data analysis (Required) * Strong working knowledge of relational database and statistical analyses (Preferred) * Strong working knowledge of QI process improvement methodology strategies - PDSA and DMAIC (Required) * Familiarity with the HEDIS, QARR, CAHPS and HOS requirements (Required) * Must possess analytical skills to collect, organize and present data in a clear and concise manner (Required) * Ability to assess all work and prioritize as necessary to meet reporting timeframes and deadlines (Required) Additional Information * Requisition ID: 1000002314 * Hiring Range: $72,000-$138,000

Summary of Job Responsible for timely and accurate load of all Professional, Facility, and Ancillary contracts across all EmblemHealth lines of business. Serve as a subject matter expert in all areas of contract configuration, fee schedules/groupers, and rate reimbursement. Develop workflows and business processes to ensure efficient interaction with Network Development, Analytics, and other business areas to facilitate accurate translation and maintenance of contractual agreements into NetworX. Serve as the subject matter expert in NetworX. Responsibilities: * Responsible for all aspects of provider, facility, and ancillary rate configurations within NetworX in accordance with set deadlines, while ensuring full accuracy of contract loads. * Collaborate with Network Management and Analytics to ensure proper capture of negotiated and modeled contractual agreements. * Responsible for the identification and correction of rate load problems. * Serve as a subject matter expert with all contract configuration, fee schedule / grouper, and rate reimbursement matters. * Analyze negotiated contracts to determine NetworX interaction with the core systems, ensuring that reimbursement is in line with negotiated intent. * Coordinate with Network Management to ensure timely update of all evergreen contracts. * Recommend contract language changes to align with system reimbursement capabilities. * Coordinate with all EmblemHeatlh towers on related NetworX issues. Qualifications: * B. S. degree in Business Operations, Information Systems or related * 3 - 5+ years of relevant experience, preferably in a health care environment (Required) * Additional experience or specialized training may be considered in lieu of educational requirements (Required) * Strong familiarity with EmblemHealth's claims systems and interdependent applications (Required) * Experience in provider, facility, and ancillary contract files set‐ups, maintenance, testing and auditing functions (Required) * Experience in establishing and accomplishing business strategies to successfully translate contractual language into system reimbursement specifications (Required) * Excellent knowledge of medical terminology, Fee Schedules, and ICD/CPT/HCPCS coding (Required) * Understanding of Government reimbursement methodologies (Required) * Strong attention to detail; strong organizational, analytic, technical, and problem‐solving skills (Required) * Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) (Required) * Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences (Required) Additional Information * Requisition ID: 1000002371 * Hiring Range: 56,160-99,360

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start **Caring. Connecting. Growing together.** The Optum Client Executive (CE) is responsible for serving as the key strategic point of contact for a portfolio of 3-7 of the enterprise's top provider clients. The CE will serve as a client's bridge across the Optum enterprise and is charged with establishing deeply embedded relationships with the clients' C-suite to earn trusted advisor status with clients. The CE will work directly with Optum and UHG C-suite level sponsors as well as business-level account owners to harness the power of the enterprise and execute strategic problem solving and innovative solutioning for clients. Through their enterprise-wide lens, the CE will drive one Optum positioning within their client portfolio and will collaborate with Optum Health, Optum Rx and Optum Insight businesses to align on customer plans and priorities. Success for this role will be represented by stellar client retention, expansion, NPS and issue resolution. The client executive will have solid critical thinking skills, demonstrated success in driving complex growth and account plan strategies, outstanding cross-group organizational skills and agility, and highly effective communication skills (verbal and written). You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. **Primary Responsibilities:** + Serving as a client advocate, assuming ownership for the client relationship and being the driving force of change while facilitating cross Optum collaboration + Builds relationships with client decision makers and influencers, understanding their needs and providing Optum solutions + Collaborates with business-level account owners to ensure seamless and cohesive end-to-end enterprise representation + Leverages UHG assets to curate and architect meaningful in-person activities that drive value and increase credibility + Recognized as a trusted voice of authority regarding strategic thought-leadership within the provider space + Develops and monitors client financial performance and profitability + Identifies whitespace opportunities, works with business partners and the client to co-create broader and more valuable solutions (for the client as well as Optum) for discussion and development + Demonstrates the value of Optum solutions and performance metrics to ensure clients are deriving the desired benefits from purchased Optum solutions + Collaborates with business partners, and direct resources across Optum, to evolve to meet client needs in bold new ways, enabling Optum to remain the industry leader in shaping the health care ecosystem + Partners with client delivery teams to ensure client expectations of service and execution are clearly understood, communicated and met + Creates and maintains Enterprise Client Plans for assigned clients. Works with the business unit leaders to execute, update and refresh the plan throughout the year + Develops a deep understanding of client organizational dynamics, business challenges, and purchasing patterns + Achieves client satisfaction and NPS goals, facilitates issue resolution and flawless service delivery You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. **Required Qualifications:** + 10+ years of progressive experience and leadership roles in the Health Care industries with a proven record of leading growth programs and delivering measurable results + 5+ years in managed services, including delivery and operation + Demonstrated experience in driving deep, productive relationships with C-Suite and Board of Directors + Demonstrated experience selling to and/or managing large provider systems + Track record of success driving client success across highly complex and matrixed organizations + History of leading, influencing and managing indirect, matrixed teams with successful people and team leadership experience - motivating, mentoring, and developing talent + Proven advanced consultative selling skills with ability to successfully construct solutions for a wide variety of unique client/market problems + Proven excellent negotiation, influencing, collaboration and listening skills + Demonstrated track record of active collaboration, engagement, oversight and strategy development of key growth opportunities + Demonstrated excellent oral and written communication skills and ability to build credibility and gain the respect and confidence of clients and internal partners + Willing and able to travel 50% of the time on a sustained basis *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy The salary range for this role is $130,000 to $240,000 annually based on full-time employment. Role is also eligible to receive bonuses based on sales performance. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives. **Application Deadline:** This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. _At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission._ _UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations._ _UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment._

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start **Caring. Connecting. Growing together.** The Practice Consultant is responsible for program implementation and provider performance management which is tracked by designated provider metrics, inclusive minimally of 4 STAR gap closure and coding accuracy demonstrating full assessment and suspect closure. The person in this role is expected to work directly with care providers to build relationships, ensure effective education and reporting, proactively identify performance improvement opportunities through analysis and discussion with subject matter experts; and influence provider behavior to achieve needed results. The person will review charts (paper and electronic - EMR), identify gaps in care and open suspect opportunities, and educate providers and offices to ensure they are coding to the highest specificity for both risk adjustment and quality reporting. Work is primarily performed at physician practices on a daily basis. If you reside in Maryland or Washington DC, you will have the flexibility to work remotely* as you take on some tough challenges. **Primary Responsibilities:** + Functioning independently, travel across assigned territory to meet with providers to discuss UHC and Optum tools and UHC incentive programs for both risk adjustment and quality reporting, focused on improving the quality of care for Medicare Advantage Members + Establish positive, long-term, consultative relationships with physicians, medical groups, IPAs and ACOs + Develop comprehensive, provider-specific plans to increase their HEDIS performance, facilitate risk adjustment suspect closure and improve their outcomes + Access PCOR to identify risk adjustment opportunities and utilize other available reporting sources including but not limited to (InSite, Spotlight, Doc360, Provider Scorecard, CPT II Report) to analyze data and prioritize gap and suspect closure, identify trends and drive educational opportunities + Conduct chart review quarterly and provide timely feedback to provider to improve reporting on a go forward basis + Conduct additional chart reviews such as a quarterly post-visit ACV review and various focused progress notes reviews with provider feedback to improve documentation and coding resulting in improved gap and suspect closure + Coordinates and provides ongoing strategic recommendations, training and coaching to provider groups on program implementation and barrier resolution + Training will include Stars measures (HEDIS/CAHPS/HOS/medication adherence), coding for quality care (CPT II) and exclusions (ICD-10-CM), risk adjustment coding practices (ICD-10-CM), and Optum program administration including use of plan tools, reports and systems + Lead regular Stars and risk adjustment specific JOC meetings with provider groups to drive continual process improvement and achieve goals + Provide reporting to health plan leadership on progress of overall performance, MAPCPi, MCAIP, gap closure, and use of virtual administrative resources + Facilitate/lead monthly or quarterly meetings, as required by plan leader, including report and material preparation + Collaborates and communicates with the member's health care and service with our interdisciplinary delivery team to coordinate the care needs for the member + Partner with providers to engage in UnitedHealthcare member programs such as HouseCalls, clinic days, Navigate4Me + Includes up to 75% local travel You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. **Required Qualifications:** To be qualified for this role you must have one of the following active coding certifications: + Certified Risk Adjustment Coder (CRC via AAPC) or Certified Professional Coder (CPC via AAPC) + If you do not have both the CRC AND CPC, it will be required to obtain both AAPC certifications within first year in position (CRC within 6 months of hire and CPC within 1 year of hire, if not currently CPC or CCS-P + 5+ years of healthcare industry experience + 1+ years of provider facing experience + Knowledge of ICD-10-CM and CPT II coding + Solid knowledge of Medicare Advantage including Stars and Risk Adjustment + Microsoft Office experience including Excel with exceptional analytical and data representation expertise + Proven solid relationship building skills with clinical and non-clinical personnel + Proven excellent oral & written communication skills + Reside in Maryland or Washington DC + Willing and able to travel at least 75% of the time in Baltimore, MD area + Current driver's license and have access to reliable transportation **Preferred Qualifications:** + Bachelor's degree (preferably in Healthcare or relevant field) + Registered Nurse + Experience working for a health plan and/or within a provider office + Experience with network and provider relations/contracting + Experience retrieving data from EMRs (electronic medical records) + Experience in management or coding position in a provider primary care practice + Knowledge base of clinical standards of care, preventive health, and Stars measures + Knowledge of billing or claims submission and other related actions + Demonstrate a level of knowledge, skill and understanding of ICD-10-CM and CPT coding principles consistent with certification by AAPC or AHIMA + Proven solid communication and presentation skills + Proven solid problem-solving skills + Proven good work ethic, desire to succeed, self-starter + Proven ability to deliver training materials designed to improve provider compliance + Proven ability to use independent judgment, and to manage and impart confidential information *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy The salary range for this role is $71,600 to $140,600 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives. **Application Deadline:** This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. _At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission._ _UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations._ _UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment._

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our mission to enhance the health and well-being of the people and communities we serve. Description - External The ideal candidate for the Manager Operations role will have a passion for effectively leading and developing a team of associates with the goal of driving operational strategies that support the growth of the business. This job can provide excellent opportunities for growth as the candidate may be required to support varying lines of business . Managing associates in completing department functions and ensuring areas of responsibility are delivering cost effective service in a quality manner by providing prompt, accurate, and professional responses. The successful applicant will have a track record managing in a fast-paced environment where competing priorities must be effectively balanced. The applicant will also have experience demonstrating the courage to honestly lead difficult conversations, coupled with the sensitivity and talent to constructively engage partners to deliver solutions for our customers, clients, brokers, and providers. Responsibilities Achieves and maintains preferred standards for the department. Manages work processes, measures for non-conformance and identifies corporate and department policies and procedures in an effort to achieve operational efficiencies Communicates, implements, and interprets corporate and departmental policies and procedures Maintains positive working relationships with internal/external customers, through direct phone contact, written correspondence, and site visits May oversee the development of the Service forecasts and capacity plans. May partner with vendors for performance, alignment, and monitoring of their forecasts and capacity plans. Creates and maintains strong relationships with clients, external consultants and brokers, and the various vendors servicing our products to facilitate and drive successful service results. Approves special consideration and handling for customers Ensures and maintains positive working relationships with group leaders, benefits administrators and account executives Collaborates with various internal departments to ensure that they fulfill all customer requests Selects, develops, appraises, and recommends compensation for associates Manages departmental budgets Manages achievement of service-level goals and key performance metrics in compliance with organizational and regulatory requirements. Manages initiatives, driving cross-functional collaboration that ensures prompt resolution of issues. Develops, implements, and monitors operations policies, procedures, and standards that support the goals and objectives of the contact center. Establishes individual performance goals for direct reports, conducts performance reviews, and provides coaching and counseling. Plans, approves, and implements programs for the development of team members. Analyzes department's performance reports. Reports on the team's progress. Ensures that the team meets productivity, quality, and service standards. Qualifications Knowledge, Skills, Abilities Must be able to develop and maintain a comprehensive, detailed knowledge of all Company Products. Demonstrated ability to assess client requests and points of friction and quickly find solutions. Must have a thorough understanding of benefits and claims processing functions. Must have the ability to manage the area of responsibility and possess managerial skills necessary for organizing, planning, controlling, budgeting, developing and motivating employees in the accomplishment of assigned tasks. Ability to work from home, which includes high-speed wi-fi capability of at least 400 Mbps and a quiet, confidential workspace. Ability to work from home, which includes high-speed wi-fi capability of at least 400 Mbps and a quiet, confidential workspace. Education This position requires an undergraduate degree, preferably in business administration. Experience A minimum of three (3) years of managerial experience. In place of a degree, five (5) to seven (7) years of management experience is required Hybrid Independence has implemented a “Hybrid” model which consists of Associates working in the office 3 days a week (Tuesday, Wednesday & Thursday) and remotely 2 days a week (Monday & Friday). This role is designated as a role that fits into the “Hybrid” model. While associates may work remotely on our designated remote days, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania. IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability. Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.

This position will provide external actuarial analytics support within the regulated Medicare market and Pharmacy Benefit Manager (PBM) Healthplan space. This actuarial strategy role is designed to provide a designated full time support to Express-Script's external client's Medicare Part D business. This role will matrix with internal leadership within trend, formulary, clinical, knowledge solutions, sales & account management, and supply teams. The role will assist in development of actuarial analyses for Medicare Part D business, including but not limited to; special CMS programs, drug expense analyses and projections, financial forecasts, actuarial modeling, pharmacy network optimization strategies, manufacturer rebates optimization, regulatory impact assessment, and ad hoc actuarial analyses as needed. The position requires an experienced strategic viewpoint in wide variety of actuarial prescription drug subjects within the enterprise, industry, and regulatory environments. The Essential Responsibilities of the Role include: Product Support / Development Co-lead development of Actuarial analytics products for Express Scripts existing Part D Plans Perform financial analyses of proposed regulatory changes, demonstration programs, and other special programs by CMS to determine financial impact on various entities within the drug supply chain Develop actuarial models to aid in prospective projections of Medicare Part D Plan client's plan liability and premium impact sensitivities Build actuarial models and project management functions to accelerate and safeguard improvements in the development of analytics tools to identify gaps in the Medicare Part D market Lead studies to aid in identification of gaps in the Medicare Part D Prescription Drug Health market to aid in development of strategies to help close identified gaps Analytics Support to Part D Plans Drive strategic discussion to develop analytics road map to optimize Part-D revenue optimization and cost-reduction strategies for Medicare Part D Health Plans: PDP, MAPD, and Special Needs Program (SNPs) Review Medicare Part D Plan bid assumptions for Regulated Medicare Part D Health Plans Create analytics for Medicare Part D Bids substantiation for Desk Review and Medicare Part D audits Utilize independent judgement and discretion to perform complex customized actuarial analyses for Part D Health Plans Cross-Functional Financial Support Collaborate with internal Express-Scripts business partners and external vendors to determine operation feasibility and financial ramifications of special programs Apply distinct Part D subject matter expertise (SME) to facilitate analytics capabilities, measure performance and aid in problem solving, and creation of actionable insights for technical teams within Express-Scripts enterprise Cross-functional collaboration within Express-Scripts enterprise Medicare Part D financial and operational strategy development. Examples include: Advanced trend analytics Medical Loss Ratio (MLR) / member profitability projections Formulary Strategy Clinical Analytics around prescription drugs pipeline products Out of Pocket Cost Member risk score analysis / benchmarking Quantification of impact of regulatory proposals and changes Regulated Part D Health Plan Financial Reconciliation Support Assimilate macro and micro trends, develop benchmarks, gather competitive intelligence to develop market competitive strategies Train and educate non-actuarial internal teams on Medicare Part D market financial and analytics components Qualifications Bachelor's degree in Actuarial Science, Economics, Statistics, Finance or other quantitative field strongly preferred 5+ years of actuarial experience or 3+ years of consulting experience ASA (or near ASA) strongly preferred; FSA preferred Part D Prescription Drug or Part D bid development consulting experience preferred Regulated Markets Medicare Part D Experience Pharmacy Benefit Manager (PBM) / Healthcare / pharmaceutical experience preferred; consulting experience strongly preferred Track record of managing multiple projects and teams that deliver client driven growth, insightful actions Proven capabilities in modeling, forecasting, and predictive analytics Strong communication and presentation skills; written/ verbal proficiency Coding skills in either SQL, R, SAS, or Python strongly preferred Preferred: Extensive understanding of US Prescription drug supply chain and Medicare knowledge, with specific acumen in Part D, including but not limited to: Part D Bid Development, Desk Review & Audits CMS Regulatory Compliance / Reporting Financial Reconciliation Modeling Trend Analyses Formulary Modeling Experience Network Optimization Modeling Rebates Modeling Market Landscape analytics Risk Score Modeling Ability to gather and analyze information, execute a map and execute strategies designed to aid in growth of existing business and building of new businesses preferred Ability to structure ambiguous actuarial and financial analyses, and synthesize and communicate complex analyses in simple and digestible data driven takeaways to internal and external senior leadership teams preferred If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.For this position, we anticipate offering an annual salary of 109,400 - 182,300 USD / yearly, depending on relevant factors, including experience and geographic location. This role is also anticipated to be eligible to participate in an annual bonus plan. We want you to be healthy, balanced, and feel secure. That's why you'll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you'll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group. About Evernorth Health Services Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives. Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws. If you require reasonable accommodation in completing the online application process, please email: ********************* for support. Do not email ********************* for an update on your application or to provide your resume as you will not receive a response. The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State. Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. We are currently seeking an Inpatient Care Management Medical Director to join our Optum team. This team is responsible for conducting acute level of care and length of stay reviews for medical necessity for our members being managed within the continuum of care. Our clients include local and national commercial employer, Medicare, and state Medicaid plans. The Medical Directors work with groups of nurses and support staff to manage inpatient care utilization at a hospital, market, regional or national level. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: Participate in telephonic outreach for collaboration with treating providers. This will include discussion of evidence - based guidelines, opportunities to close clinical quality / service gaps, and care plan changes that can impact health care expenses Responsible to collaborate with operational and business partners on clinical and quality initiatives at the site and customer level to address customer expectations Is grounded in the use and application of evidence-based medicine (EBM) such as InterQual care guidelines and criteria review Occasionally, may participate in periodic market oversight meetings with the outward facing Chief Medical Officers, network contractors, nurse management and other internal managers Maintain proficiency in all required software and platforms Although the United Health Services ICM Medical Director's work is typically concentrated in a region, they are part of a national organization and team, and collaborate with peers, nurse managers, and non-clinical employees from across the country. In response to customer needs and expectations, Optum is continuously modifying its programs and approaches. Although not a primary job function, Medical Directors with the interest in doing so often can be involved with change design and management. You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: MD or DO with an active, unrestricted medical license Current Board Certification in an ABMS or AOBMS specialty 3+ years of clinical practice experience post residency Private home office and access to high-speed Internet Technical proficiency in computer software and systems Preferred Qualifications: Licensure in either HI, AK, OR, ID, WA, UT a plus 2+ years of managed care, Quality Management experience and/or administrative leadership experience Prior UM experience Clinical experience within the past 2 years *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.

Optum Home & Community Care, part of the UnitedHealth Group family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual's physical, mental and social needs - helping patients access and navigate care anytime and anywhere. As a team member of our navi Health product, we help change the way health care is delivered from hospital to home supporting patients transitioning across care settings. This life-changing work helps give older adults more days at home. We're connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together. There are changes happening in health care that go beyond the basics we hear in the news. People like you and organizations like UnitedHealth Group are driving ever higher levels of sophistication in how provider networks are formed and operate. The goal is to improve quality of service while exploring new ways to manage costs. Here is where you come in. You will use your solid customer service orientation and knowledge of insurance claims to serve as an advocate for providers in our networks. As you do, you will discover the impact you want and the resources, backing and opportunities that you would expect from a Fortune 4 leader. A highly engaged provider network is critical to ensure members receive the right care at the right place for the right amount of time. The Provider Relations Manager develops and maintains an ongoing collaborative relationship with providers, based on mutual respect, high-quality outcomes, and patient satisfaction. The role works to continually shape the network landscape, by offering objective data and education to all stakeholders in the market. In its highest functional state, it is the Provider Relations Manager who supports the provider in ensuring recognition by the hospital and plan partners through appropriate application of best practices in quality, efficiency, and process management. The market for this role is Tennessee, Alabama, Mississippi, and Louisiana. Why navi Health? At navi Health, our mission is to work with extraordinarily talented people who are committed to making a positive and powerful impact on society by transforming health care. navi Health is the result of almost two decades of dedicated visionary leaders and innovative organizations challenging the status quo for care transition solutions. We do health care differently and we are changing health care one patient at a time. Moreover, have a genuine passion and energy to grow within an aggressive and fun environment, using the latest technologies in alignment with the company's technical vision and strategy. If you are located in Tennessee, Alabama, Mississippi or Louisiana, you will have the flexibility to work remotely* as you take on some tough challenges. Primary Responsibilities: * Develop relationships with providers/payers and support the patient-centric model during new implementations * Maintain positive working relationships with providers/payers to build a high quality, highly receptive network base in mature markets * Lead network issue resolution * Deliver ongoing analytics and support materials for providers * Work closely with market presidents and senior clinical managers to monitor and improve hospital DC referral patterns, par and non-par home health agencies, and closed record statistics * Collaborate closely with provider relations leadership * Coach, provide feedback and guide others * Assist in efforts to enhance ease of use of provider portal and future services enhancements * Contribute to design and implementation of programs that build/nurture positive patient and provider experiences * Help implement training and development of external providers through education programs * Identify gaps in network composition and services to assist network contracting and development teams You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: * Healthcare experience * 3+ years of experience collaborating with providers or related account management roles * Driver's License and access to a reliable transportation Preferred Qualifications: * Clinical licensure - RN, PT, OT, or ST * 5+ years of health care/managed care experience * 3+ years of provider relations and/or provider network experience * Experience across the acute and post-acute care continuum * Proficiency in claims processing and issue resolution * Proficiency with MS Word, Excel, PowerPoint, and Access * All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy The salary range for this role is $71,600 to $140,600 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

**Become a part of our caring community and help us put health first** The Associate Actuary, Analytics/Forecasting analyzes and forecasts financial, economic, and other data to provide accurate and timely information for strategic and operational decisions. Establishes metrics, provides data analyses, and works directly to support business intelligence. Evaluates industry, economic, financial, and market trends to forecast the organization's short, medium and long-term financial and competitive position. The Associate Actuary, Analytics/Forecasting work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Associate Actuary, Analytics/Forecasting ensures data integrity by developing and executing necessary processes and controls around the flow of data. Collaborates with stakeholders to understand business needs/issues, troubleshoots problems, conducts root cause analysis, and develops cost effective resolutions for data anomalies. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments. This role is part of the Consumer Growth - Membership Analytics team. As a part of this team, individuals will work closely with the Consumer Growth Strategy Team to guide and evaluate Humana's growth initiatives, particularly around strategies related to segmentation of our members. This role will directly collaborate with various business partners including initiative owners and finance stakeholders. Candidates pursuing this role should be passionate about combining actuarial analytics skills with business knowledge to help our partners devise the best strategies to help Humana grow. This role can work remotely from anywhere in the United States but is expected to work wither Eastern or Central hours. **Use your skills to make an impact** **Required Qualifications** + Bachelor's Degree + Associate of Society of Actuaries (ASA) designation + Meets eligibility requirements for Humana's Actuarial Professional Development Program (APDP) + MAAA + Strong communication skills + Knowledge of medical insurance (preferably Medicare Advantage) **Work-At-Home Information** To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: + At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. + Satellite, cellular and microwave connection can be used only if approved by leadership. + Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. + Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. + Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **Scheduled Weekly Hours** 40 **Pay Range** The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $106,900 - $147,000 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. **Description of Benefits** Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Application Deadline: 06-08-2025 **About us** Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large. **Equal Opportunity Employer** It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our ***************************************************************************

Summary of Job Responsible for the day-to-day operation and performance of the care management team providing care management services to EmblemHealth members. Utilize data to monitor team member performance (quality, outcome and productivity measures, etc.); deploy strategies to improve performance. Provide coaching and mentoring to team members to address performance related issues. Use problem solving abilities to create solutions to operational and clinical issues identified during day-to-day operations. Collaborate with the Director and AVP of Care Management and internal audit teams to address audit related findings and implement performance improvement strategies. Develop job aides, work flows and other tools to enhance delivery of care management services. Collaborate with other functional areas within organization to ensure that Care Managers are implementing EmblemHealth Health Plans policies, procedures and all regulatory mandates, consistent with Emblem Health Plans mission, vision, purpose and value statement. Responsibilities * Manage daily operations of the Care Management team including measurement of performance metrics and productivity standards; implement, deploy, and reinforce strategies to improve performance. * Train employees in process operations; act as a preceptor to newly hired staff. * Complete quarterly evaluations of staff as needed. * Monitor team caseloads; shift workloads accordingly to meet departmental/organizational needs. * Monitor timeliness and appropriateness of documentation in clinical systems to ensure that documentation meets accreditation and regulatory standards. * Ensure that team members are managing enrollees across the care continuum, inclusive of behavioral health, so that enrollees have access to needed care and services. * Serve as a clinical resource; attend Care Management rounds. * Monitor employees' performance regularly and coach employees as needed. * Perform other related tasks as directed or required. Qualifications * Bachelor's degree, preferably in Nursing (Required) * Current New York State RN or LSCSW license (Required) * CCM certification (Preferred) * 5 - 8+ years of clinical experience (Required) * Health plan experience (Preferred) * May be required to manage Long-Term Services and Supports (LTSS) cases (Preferred) * Experience leading care management teams (Required) * Detail oriented; strong analytical and problem-solving skills; ability to execute on strategy (Required) * Ability to organize, prioritize, and effectively manage multiple tasks with competing priority levels and deadlines (Required) * Excellent communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences (Required) * Proficient with MS Office - Word, Excel, PowerPoint, Outlook, Teams, etc. (Required) * Able to analyze problems and recommend and deploy strategies to improve performance in collaboration with the leadership team (Required) Additional Information * Requisition ID: 1000002386 * Hiring Range: $77,760-$149,040

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start **Caring. Connecting. Growing together.** The Optum Client Executive (CE) is responsible for serving as the key strategic point of contact for a portfolio of 3-7 of the enterprise's top state and federal government clients. The CE will serve as a client's bridge across the Optum enterprise and is charged with establishing deeply embedded relationships with the clients' C-suite to earn trusted advisor status with clients. The CE will work directly with Optum and UHG C-suite level sponsors as well as business-level account owners to harness the power of the enterprise and execute strategic problem solving and innovative solutioning for clients. Through their enterprise-wide lens, the CE will drive one Optum positioning within their client portfolio and will collaborate with Optum Health, Optum Rx and Optum Insight businesses to align on customer plans and priorities. Success for this role will be represented by stellar client retention, expansion, NPS and issue resolution. The client executive will have solid critical thinking skills, demonstrated success in driving complex growth and account plan strategies, outstanding cross-group organizational skills and agility, and highly effective communication skills (verbal and written). You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. **Primary Responsibilities:** + Responsible for serving as a client advocate, assuming ownership for the client relationship and being the driving force of change while facilitating cross Optum collaboration + Builds relationships with client decision makers and influencers, understanding their needs and providing Optum solutions + Collaborates with business-level account owners to ensure seamless and cohesive end-to-end enterprise representation + Leverages UHG assets to curate and architect meaningful in-person activities that drive value and increase credibility + Recognized as a trusted voice of authority regarding strategic thought-leadership within the state and federal government space + Develops and monitors client financial performance and profitability + Identifies whitespace opportunities, works with business partners and the client to co-create broader and more valuable solutions (for the client as well as Optum) for discussion and development + Demonstrates the value of Optum solutions and performance metrics to ensure clients are deriving the desired benefits from purchased Optum solutions + Collaborates with business partners, and direct resources across Optum, to evolve to meet client needs in bold new ways, enabling Optum to remain as the industry leader in shaping the health care ecosystem + Partners with client delivery teams to ensure client expectations of service and execution are clearly understood, communicated and met + Creates and maintains Enterprise Client Plans for assigned clients. Works with the business unit leaders to execute, update and refresh the plan throughout the year + Develops a deep understanding of client organizational dynamics, business challenges, and purchasing patterns + Achieves client satisfaction and NPS goals, facilitates issue resolution and flawless service delivery You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. **Required Qualifications:** + 10+ years of progressive experience and leadership roles in the Health Care industries with a proven record of leading growth programs and delivering measurable results + 5+ years in managed services, including delivery and operation + Experience in driving deep, productive relationships with C-Suite and Board of Directors + Experience selling to and/or managing state and federal government entities + Track record of success driving client success across highly complex and matrixed organizations + History of leading, influencing and managing indirect, matrixed teams with successful people and team leadership experience - motivating, mentoring, and developing talent + Advanced consultative selling skills with ability to successfully construct solutions for a wide variety of unique client/market problems + Demonstrated track record of active collaboration, engagement, oversight and strategy development of key growth opportunities + Demonstrated excellent negotiation, influencing, collaboration and listening skills + Demonstrated excellent oral and written communication skills and ability to build credibility and gain the respect and confidence of clients and internal partners + Willing and able to travel 50% of the time on a sustained basis *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy The salary range for this role is $130,000 to $240,000 annually based on full-time employment. Role is also eligible to receive bonuses based on sales performance. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives. **Application Deadline:** This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. _At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission._ _UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations._ _UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment._

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start **Caring. Connecting. Growing together.** Positions in this function research and investigate key business problems through quantitative analyses of utilization and healthcare costs data. Provides management with statistical findings and conclusions. Identifies potential areas for medical cost improvements and alternative pricing strategies. Provides data in support of actuarial, financial and utilization analyses. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. **Primary Responsibilities:** + Identify, create, and develop a portfolio of cost savings initiatives that drive specific and measurable results for assigned clients while providing timely and meaningful client updates + Perform and participate in iterative analytical, experimental, investigative, and other fact-finding work in support of concept development + Establish solid matrixed relationships with internal stakeholders to define, align, and deliver payment integrity initiatives in support of assigned clients + Influence senior leadership to adopt new ideas, approaches, and/or products + Recommend changes to current product development procedures based on market research and new trends + Industry thought leader and subject matter expert for medical claims, related trends, pricing, and cost management initiatives + Lead concepts/projects from conceptualization to completion You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. **Required Qualifications:** + 4+ years of experience auditing, billing, and/or coding claims within the Molecular/Genetic area + 4+ years of experience in the health care industry (Medicare, Medicaid, Commercial) with deep exposure to Payment Integrity or Revenue Integrity + 3+ years of work experience in highly collaborative and consultative roles, with ability to establish credibility quickly with all levels of management across multiple functional areas + 2+ years of experience performing research and analysis of claims data and applying results to identify trends/patterns + 2+ years of experience presenting proposals to stakeholders and internal customers + Project Management experience + Maintains working knowledge of CMS rules and regulations and billing codes and related services **Preferred Qualifications:** + Undergraduate Degree + Advanced degree in health care or medical field + Coding certification through AAPC or AHIMA + 3+ years of experience in claims adjudication or revenue cycle management + 2+ years of experience working in a matrixed and highly adaptive environment handling tight deadlines + Experience working in a Laboratory and/or Genetics setting + Proficiency with SQL, SAS and/or other statistical programs + Solid computer skills: Excel (Pivot Tables, Advanced Formulas, macros, etc..), Visio, PowerPoint, Tableau + Proven solid project management approach with excellent critical thinking and problem-solving skills + Proven self-managed, self-starter with the ability to support multiple concurrent projects and meet tight delivery timelines + Proven exceptional presentation, communication, and negotiation skills *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy The salary range for this role is $106,800 to $194,200 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives. **Application Deadline:** This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. _At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission._ _UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations._ _UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment._