Elevance Health

Pharmacist

• Complete work related to the Pharmacy and Therapeutics Committee, including therapeutic class reviews, policy review, drug monographs, and formulary recommendations
• Develop strategies to drive formulary utilization and optimization
• Complete a year-long project targeted at improving member care through proper medication management
• Perform weekly clinical prior authorizations and coverage determinations for Medicaid and Medicare
• Participate in pharmaceutical care management by reviewing member profiles and recommending members for lock-in, case management, or disease management
• Respond to and resolve member/provider complaints, claims processing issues, and appeals

Managed Care Pharmacy Resident

Program Manager

• Lead the enterprise Voice of the Customer operating model to reduce Consumer Effort across calls, chat, and digital interactions
• Run the cross-functional VoC Command Center, including hotspot reviews, root-cause discussions, owner follow-up, action tracking, and executive updates
• Direct development, planning, prioritization, approval, implementation, and governance of enterprise VoC and Consumer Effort programs
• Manage VoC intake, prioritization, roadmap, backlog, decision log, risk register, and benefits tracking
• Partner with Analytics, Digital, Operations, Product, Clinical, Pharmacy, Provider, Technology, Compliance, corporate, and regional business teams
• Research relevant practices and stay current on industry trends and emerging AI-enabled capabilities
• Use AI-enabled tools for topic discovery, sentiment analysis, verbatim summarization, anomaly detection, journey diagnostics, and executive storytelling
• Ensure AI outputs are human-reviewed, explainable, and appropriate for a regulated healthcare environment
• Facilitate cross-functional action sprints and develop communication materials, training criteria, presentations, and program reporting
• Identify opportunities for virtual assistants, agent assist, self-service, knowledge management, proactive outreach, or agentic AI to reduce member effort
• Manage leadership communications and executive-ready updates
• Provide leadership to program managers and project managers
• Improve Consumer Effort Scores across priority member journeys, channels, and high-friction experiences
• Strengthen VoC issue detection, prioritization, ownership, action tracking, and benefits measurement
• Accelerate root-cause identification and resolution of member pain points
• Provide visibility into enterprise CX priorities, AIP Consumer Effort targets, and business impact

Program Director, Voice of the Customer (VoC) Insights

• Serve as a liaison and oversee quality improvement activities, projects, and programs for one or more states within a major line of business
• Support Accreditation readiness activities and ensure ongoing compliance with Accreditation standards, especially NCQA requirements and regulatory expectations
• Lead state-level quality strategy meetings and develop quality plans integrated into business processes
• Serve as subject matter expert and quality lead for Accreditation readiness, including interpretation, implementation, monitoring, and documentation of NCQA standards
• Partner with business leaders and cross-functional teams to establish, track, and achieve Accreditation milestones, deliverables, and readiness activities
• Work with clinical intervention teams to design studies identifying barriers to medical interventions
• Ensure sound study methodology and appropriate reporting
• Develop performance improvement plans and oversee clinical quality improvement activities to improve member care
• Ensure compliance with corporate QI work plans and relevance of QI activities to targeted populations
• Maintain research-program documentation meeting regulatory and Accreditation standards
• Coordinate Accreditation work plans, evidence collection, gap assessments, readiness reviews, submissions, and surveys
• Oversee accurate quantitative analysis of clinical data and presentation of results
• Participate in development of new product designs for a major line of business
• Oversee implementation of new initiatives
• Collaborate with operational, clinical, compliance, accreditation, and business partners to drive process improvements and quality outcomes
• Lead interactions with regulators or oversight entities
• Oversee quality improvement activities for complex state programs
• Identify opportunities to improve processes, workflows, documentation practices, and operational controls
• Develop and deliver education, guidance, and consultation on Accreditation requirements, quality standards, and readiness expectations

Clinical Quality Program Manager

Consultant

• Develop and manage one or more external client-facing programs within a business unit
• Support business strategies through an integrated portfolio of external client-facing projects or initiatives
• Manage ongoing compliance and daily operations for external client-facing programs under the supervision of the Manager II
• Help ensure programs meet stated objectives
• Provide day-to-day operational support to a team of advisors
• Research applicable subject-matter practices and monitor industry trends
• Coordinate training related to the external client-facing program
• Support program success measures and assist with data collection related to program success

Clinical Care Advisor, IDD – Program Consultant

Auditor

• Identify issues and/or entities that may pose potential risk associated with fraud and abuse
• Examine claims for compliance with relevant billing and processing guidelines
• Identify opportunities for fraud and abuse prevention and control
• Review and analyze claims and medical records prior to payment
• Use required systems/tools to accurately document determinations and continue to the next step in the claims lifecycle
• Research healthcare-related questions to aid investigations
• Stay current on medical coding and billing issues, trends, and legal/regulatory changes
• Collaborate with the Special Investigation Unit and other internal areas
• Recommend interventions for loss control and risk avoidance based on investigation outcomes
• Assist with training new associates

Clinical Provider Auditor II

Manager

• Work with management to identify and implement varied projects, programs, and plans supporting business unit and enterprise goals.
• Identify potential issues, project charge, and scope.
• Lead efforts to identify best practices.
• Identify impacted parties, business partners, and required resources.
• Develop and design processes and systems that support business needs.
• Design methods for integrating functions and processes.
• Conduct cost/benefit analyses.
• Build support for business change throughout the business unit.
• Lead end-to-end UAT activities, including strategy, planning, execution, regression, defect management, business sign-off, and production validation.
• Partner with Business, Product, IT, Operations, and SMEs and provide status, risk, and release-readiness reporting to senior leadership.
• Lead onshore/offshore testing resources and manage work allocation, dependencies, escalations, and project status.
• Drive activities through successful production implementation.

Business Change Manager

• 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
• Provide resolution to grievances and appeals issues
• Respond to medication-related inquiries from patients, providers, and team members
• Receive calls from members to address medication or pharmacy-related needs
• Assist with medication adherence, prior authorization processing, medication reconciliation, and troubleshooting cost and medication access issues

Pharmacy Technician II

Account Executive

• Build and maintain relationships with key customers, including physicians, urgent care centers, infusion clinics, hospitals, skilled nursing centers, and payors
• Work with leadership to develop territory sales forecasts and goals
• Qualify territory opportunities involving private insurance and/or federal or state funded plans and potential revenue
• Identify and resolve customer service issues in the territory
• Assist customer service and provide information to meet customer needs
• Network with industry partners
• Partner with team members, leadership, and principals to close deals and negotiate deliverables
• Assess and report on competitive sales activities
• Assist in developing and implementing competitive sales strategies
• Represent the region in sales efforts
• Travel to client sites or designated locations, with occasional office attendance for meetings or training

Hemophilia Account Executive – Paragon Healthcare

• Provide 24/7 Behavioral Health and Employee Assistance services
• Respond to initial customer contacts and requests for EAP services
• Receive client requests, assess situations, and determine appropriate courses of action
• Provide telephone and/or on-site crisis intervention, assessment, short-term problem resolution, and referrals
• Manage Critical Incident Stress Debriefing requests
• Assess members and help them access behavioral healthcare benefits under their health plans
• Manage the shared mailbox and review information for placement in the documentation system

Behavioral Health, EAP Consultant I

Analyst

• Drive service quality excellence by evaluating the quality of enterprise services and interactions
• Evaluate enrollment and billing, claims processing, and customer service written and verbal inquiries
• Assist higher-level auditors/leads with assigned field work
• Perform special and targeted audits requested by internal management
• Participate in pre- and post-implementation audits of providers, claims processing and payment, benefit coding, member and provider inquiries, enrollment and billing transactions, and corrective action plans
• Analyze and interpret data and make recommendations for change
• Apply audit policy and assess risks to minimize exposure and mitigate risks
• Document audit results and findings
• Suggest appropriate remediation

Performance Quality Analyst I

Nurse

• Review complex and challenging cases requiring nursing judgment, critical thinking, and holistic assessment
• Determine whether requested services are medically necessary
• Work with healthcare providers to understand and assess members’ clinical presentations
• Provide consultation to the Medical Director on unclear or complex cases
• Serve as a resource for clinicians and lower-level nurses
• Analyze members’ clinical information and apply clinical guidelines and policies to evaluate medical necessity
• Promote quality member outcomes, optimize member benefits, and support effective resource utilization
• Assess complex clinical concepts, symptoms, and aggregate member information
• Identify inappropriate type, level, or quality of care
• Recommend alternate types, places, or levels of appropriate care
• Collaborate with case management nurses on discharge planning
• Ensure patients have appropriate equipment, environment, and education for safe discharge
• Participate in intradepartmental and cross-functional teams, projects, initiatives, and process improvement activities
• Educate members about plan benefits and physicians and assist with case management
• Collaborate with leadership to enhance training and orientation materials
• Complete quality audits and assist with corrective action plans
• Assist leadership and stakeholders with process improvement initiatives
• Help train lower-level clinician staff

Medical Management Nurse – Weekends

• Perform care management within the scope of licensure for members with complex and chronic care needs
• Assess members and develop, implement, coordinate, monitor, and evaluate care plans
• Optimize member healthcare across the care continuum
• Ensure member access to services appropriate to their health needs
• Facilitate authorizations and referrals within the benefits structure or through extra-contractual arrangements
• Coordinate internal and external resources to meet identified needs
• 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
• Perform duties telephonically or on-site, including at hospitals for discharge planning

Nurse Case Manager I

Full-stack Engineer

• Deliver end-to-end applications, system development, and maintenance across complex multi-technology platforms
• Maintain active customer relationships to determine business requirements
• Lead requirements-gathering meetings
• Own the change request process and coordinate with other teams as necessary
• Provide technical advice and influence technical decisions affecting cross-functional teams
• Research and propose new technologies
• Develop and own the list of final enhancements
• Define application scope and objectives
• Prepare technical and/or functional specifications
• Perform technical design reviews and code reviews
• Own technical testing, ensuring unit and system testing meet requirements and implementation plans
• Assess current status and support data information planning
• Coordinate on-call support and ensure effective system monitoring
• Maintain the technical development environment
• Mentor others and lead multiple small-to-medium-sized projects
• Set direction at the project/service level and influence decision-making
• Provide technical guidance and mentoring
• Evaluate tradeoffs between technical, analytical, and product needs
• Identify strategies for technical problems, communicate standards, and gain buy-in
• Facilitate requirements clarification, design, code review, and troubleshooting sessions
• Support vendor evaluation

Full Stack Developer

• Review, audit, and code medical records for reimbursement, training, education, and compliance
• Audit and review medical documentation for appropriate ICD-9 and CPT coding and documentation
• Query physicians when code assignments are not straightforward or documentation is unclear
• Train and educate others on coding documentation, claim payment guidelines, and related issues
• Review CPT and ICD-9 codes annually for accuracy and implement changes
• Assist physicians and providers with coding, documentation, and billing questions and problems
• Serve as a resource to Coding Analysts

Senior Coding Analyst

• Manage psychiatric and substance abuse or substance abuse disorder facility-based and outpatient professional treatment health benefits through telephonic or written review
• Use screening criteria knowledge and clinical judgment to assess member needs
• Ensure access to medically necessary, quality behavioral healthcare in a cost-effective setting according to UM Clinical Guidelines and contract
• Refer cases to Peer Reviewers as appropriate
• Coordinate, implement, plan, monitor, and evaluate psychiatric and substance abuse assessments
• Promote quality member outcomes and optimize member health benefits
• Promote effective use of health benefits and community resources
• Handle crisis calls and assess members for safety