Elevance Health

Consultant

• Employ advanced analytics to gain insights into member behavior drivers and preferences, product/program concepts and value propositions, operational effectiveness and efficiencies, and client-specific health gaps and needs
• Consult business leaders and internal partners to apply insights to test and drive product innovation and enhancement
• Measure program outcomes and demonstrate value
• Help win and retain clients and support information-based strategic decision making
• Provide analytical insights for business solution development based on quality, use, cost and other key drivers
• Develop and refine analysis templates for problem diagnosis and opportunity assessment
• Consult on designing and executing tests or pilot programs
• Contribute to new program and initiative design based on test/pilot outcomes
• Develop targeting criteria and customer segmentation based on analytical, clinical, product and operations inputs
• Develop predictive models and other tools to target the right members
• Develop methodologies to measure clinical, utilization and financial outcomes
• Conduct in-depth research on challenging issues in measuring outcomes
• Lead applied research projects
• Author white papers, present at industry conferences and submit journal publications
• Address limitations of data sources and evaluate the incremental value of new data sources

Advanced Analytics Consultant

Technician

• Conduct research and collect and enter data for complex and moderately varied issues and situations
• Collect data
• Input data to spreadsheets and databases
• Update databases as needed
• Attend required in-person training sessions
• Work virtually full-time, with flexibility and autonomy
• Support federal programs through claims administration, data, and care delivery solutions

SCA Data Technician

Manager

• Perform telephonic care management for members with complex and chronic care needs
• Assess members and develop individualized care management plans
• Implement care plans by facilitating authorizations and referrals within the benefits structure or through extra-contractual arrangements
• Coordinate internal and external resources to meet identified needs
• Monitor and evaluate care management plan effectiveness and modify plans as necessary
• Interface with Medical Directors and Physician Advisors on care management treatment plans
• Negotiate reimbursement rates, as applicable
• Assist with provider, claims, or service issue problem-solving
• Assist with developing utilization and care management policies and procedures
• Ensure member access to services appropriate to their health needs

Telephonic Nurse Case Manager II

Pharmacist

• Assist with medication adherence
• Process prior authorizations
• Perform medication reconciliation
• Troubleshoot cost and medication access issues
• Verify member information and input medication data
• Ensure medication access and adherence to optimize health
• Educate members on pharmacy-based prescription rules and medication resources or assistance programs
• Process prior authorization requests from physicians’ offices
• Ensure compliance with Medicare and Medicaid requirements
• Inform relevant parties of prior authorization determinations
• Resolve grievance and appeal issues
• Respond to medication-related inquiries from patients, providers, and team members
• Receive calls from members to address medication or pharmacy-related needs

Pharmacy Tech II

Nurse Practitioner

• Provide primary and urgent healthcare by telephone and tele-video to patients receiving home and community-based services
• Develop and implement clinical care plans for adults with chronic and complex conditions
• Gather medical histories, conduct physical examinations, obtain diagnostics as needed, and create treatment plans
• Identify and close gaps in care
• Address patients’ and families’ physical and psychosocial needs with interdisciplinary team support
• Educate patients and families about medications, side effects, illness progression, diet, nutrition, adherence, and crisis prevention
• Coordinate care and resources with company physicians, other physicians, medical providers, patients, families, and clinical team members
• Maintain patient medical records and documentation in accordance with regulations and company standards
• Participate in required continuing education
• Prescribe medication as permitted by state authority
• Provide clinical and non-clinical patient support

Nurse Practitioner, Bilingual

Customer Support

• Complete required basic training
• Respond to customer questions via telephone and written correspondence regarding insurance benefits, provider contracts, eligibility, and claims
• Analyze problems and provide information and solutions
• Operate a PC/image station to obtain and extract information
• Document information, activities, changes, and inquiry outcomes in the database
• Develop and maintain positive customer relations
• Coordinate company functions to handle customer requests and questions appropriately and promptly
• Research and analyze data to address operational challenges and customer service issues
• Provide external and internal customers with requested information
• Receive and place routine follow-up telephone calls and emails
• Use computerized systems for tracking, information gathering, and troubleshooting
• Seek, understand, and respond to internal and external customer needs and expectations
• Perform other duties as assigned

Customer Care Representative – Bilingual

Referral Specialist

• Take inbound calls, texts, and chats from individuals needing support, services, or who may be in crisis
• Perform safety screenings and assessments to determine the presence and acuity of risk to the individual or others
• Use caller information and screening/assessment results to understand needs and develop a plan of action collaboratively
• Complete timely and accurate documentation of interactions according to established criteria
• Provide linkage follow-up to ensure individuals accessed services
• Coordinate with agencies, organizations, and individuals to optimize use of resources, services, and natural support systems
• Ensure compliance with HIPAA, OSHA, and other federal, state, and local regulations
• Participate in required in-person training sessions; training is Monday-Friday, 10:00am-6:30pm EST

Crisis & Referral Specialist

Representative

• Manage incoming calls, including triage, opening of cases and authorizing sessions
• Manage incoming calls or incoming post services claims work
• Determine contract and benefit eligibility
• Provide authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests
• Obtain intake and demographic information from callers
• Conduct thorough radius searches in Provider Finder and follow up with providers on referrals
• Refer cases requiring clinical review to nurse reviewers
• Handle referrals for specialty care
• Process incoming requests and collect information needed for review from providers
• Utilize scripts to screen basic and complex requests for precertification and/or prior authorization
• Verify benefits and eligibility information
• Act as liaison between Medical Management and internal departments
• Respond to telephone and written inquiries from clients, providers and in-house departments
• Conduct the clinical screening process

Utilization Management Representative II

• Manage incoming calls, including triage, case opening, session authorization, and support for timely prior authorization decisions
• Manage incoming post-service claims work, including specialty infusion prior authorization requests for high-cost therapies
• Determine contract and benefit eligibility
• Provide authorization for inpatient admission, outpatient precertification, prior authorization, and post-service requests
• Submit, track, and follow up on authorizations
• Obtain demographic intake information from callers
• Conduct radius searches in Provider Finder and follow up with providers on referrals
• Refer cases requiring clinical review to nurse reviewers and handle specialty-care referrals
• Process incoming requests and collect information from providers using scripts to screen precertification and prior authorization requests
• Review supporting documentation, including clinical notes and labs when applicable, against payer-specific criteria
• Verify benefits and eligibility, coordinating with commercial insurance, Medicare/Medicaid, and PBMs
• Act as liaison between Medical Management and internal departments
• Respond to telephone and written inquiries from clients, providers, and in-house departments
• Communicate authorization status updates to providers and clinical staff
• Support denial follow-up by coordinating additional medical-necessity information
• Conduct clinical screening and document authorization details, including approval dates and reference numbers, in the system

Operations

• Identify opportunities for improvement
• Research, develop, and implement related best practices
• Develop metrics to track performance and goal achievement
• Serve as an internal consultant for continuous improvement initiatives
• Identify and develop plans to improve performance for enterprise-wide implementation
• Travel to worksites and other locations as necessary

Senior Process Improvement Manager

Business Intelligence Developer

• Participate in all phases of the design and development life cycle of analytic applications and reporting tools
• Maintain active relationships with customers to determine business requirements
• Anticipate opportunities for improvement and identify alternate solutions
• Collaborate with engineers on Web portals supporting interactive content
• Analyze and classify complex change requests and evaluate possible enhancements
• Define application scope and objectives and prepare functional or technical specifications
• Analyze and evaluate detailed business and technical requirements
• Code and maintain complex information-system components
• Mentor others on coding standards and perform code reviews
• Develop and perform system testing, fix defects, and re-execute unit tests
• Integrate activities with other IT departments for successful implementation and project support
• Support data information planning efforts
• Maintain the technical development environment and implementation plan
• Assist with training documentation and identify additional needs and enhancements
• Manage small projects, mentor, and train others
• Serve as subject matter expert for Business Intelligence applications
• Establish connectivity to operations source systems and data repositories
• Conduct data discovery to assess data strengths, limitations, and opportunities
• Develop strategic reporting applications from the data warehouse using SQL
• Maintain knowledge of data warehouse database design, data definitions, and data integrity issues
• Collaborate with database developers, data analysts, project managers, program managers, IT engineers, and external partners
• Help performance-tune SQL queries for business-essential processes and service-level agreements

Senior Business Intelligence Developer

• Translate moderately complex and varied business needs into application software requirements
• Determine specific business application software requirements for complex and varied business needs
• Analyze and design solutions addressing complex and varied business needs
• Consult with business partners regarding application and technology implementation
• Consider business implications of applying technology to current and future business environments

Business Consultant

• Perform care management within scope of licensure for members with complex and chronic care needs
• Assess, develop, implement, coordinate, monitor, and evaluate care plans across the care continuum
• Perform duties telephonically or on-site, including at hospitals for discharge planning
• Ensure member access to services appropriate to health needs
• Conduct assessments and identify individual needs and care management objectives
• Facilitate authorizations and referrals within the benefits structure or through extra-contractual arrangements
• Coordinate internal and external resources to meet identified needs
• Monitor and evaluate care plan effectiveness and modify plans as necessary
• Interface with Medical Directors and Physician Advisors on care management treatment plans
• Assist with provider, claims, or service issues
• Function as preceptor for new care management staff
• Work on special projects assigned by the manager
• Perform other duties as assigned

Nurse Case Manager I

• Manage and support change management aligned with transformational business initiatives and enterprise-wide stakeholders.
• Embed user adoption through change management practices into business strategies to achieve desired business outcomes.
• Apply structured change management methodology to facilitate change and promote adoption.
• Identify the need for agility and modify approaches to meet stakeholder needs.
• Lead, coordinate, and provide visibility into engagement, communications, and training efforts for enterprise transformation initiatives.
• Provide strategic consultation and execution to support adoption of change initiatives and necessary behavioral shifts.
• Prepare stakeholders by assessing change magnitude, complexity, organizational readiness, and associated risks.
• Conduct methodological analysis of change impacts and identify key stakeholders affected by change.
• Conduct environment scans to identify challenges and stakeholder resistance, including skills gaps, doubts, and uncertainties.
• Create and deliver engagement and communications plans.
• Solicit stakeholder feedback to measure change management success and inform change strategies.
• Collaborate with Culture Transformation, Communications, Human Resources, Technology, Global Service teams, and Enterprise Transformation leaders.
• Apply enterprise standards across change interventions, aligning with Responsible AI and internal best practices.

Enterprise Change Management Consultant

• Collaborate with company physicians, patients’ other physicians and providers, and family members to develop complex plans of care
• Provide clinical and non-clinical support to patients
• Provide primary and urgent health care via telephone and tele-video modalities
• Develop and implement clinical plans of care for adult patients with chronic and complex conditions
• Gather histories, physical examinations, and diagnostics as needed
• Develop and implement treatment plans based on patient goals and current conditions
• Identify and close gaps in care
• Address patients’ and families’ physical and psychosocial needs with interdisciplinary team support
• Educate patients and families about medications, side effects, illness progression, diet and nutrition, adherence, and crisis prevention
• Coordinate care and resources with clinical team members, physicians, and medical providers
• Maintain patient medical records and documentation
• Participate in continuing education
• Prescribe medication as permitted by state authority
• Work Monday–Friday, 8:00 a.m.–5:00 p.m., with rotating on-call coverage 2–3 days per month from 5:00 p.m.–8:00 a.m.