Elevance Health

Pharmacist

• Respond to basic customer questions by telephone and written correspondence about pharmacy retail and mail order prescriptions
• Develop and maintain positive customer relations
• Coordinate with company functions to handle and resolve customer requests appropriately and promptly
• Provide claims, customer service, and/or membership support to subscribers, providers, group or benefit administrators, physician offices, third-party representatives, and other Blue Cross Plans
• Conduct research to provide proactive and thorough solutions
• Own service requests through high-quality resolution and follow-through
• Support and guide customers regarding personal options and decisions
• Help customers become knowledgeable and confident in using available technology, tools, and resources

Pharmacy Customer Associate I

• Perform care management activities within the scope of licensure for members with complex and chronic care needs, particularly oncology and REMS programs
• Ensure medically appropriate, high-quality, cost-effective care and treatment appropriateness
• Partner with physicians and/or pharmacists on care appropriateness, intervention planning, and clinical guidance
• Collaborate with providers to identify consumer needs, adverse events, and continuity-of-care requirements
• Conduct clinical assessments and develop individualized goals and care plans
• Monitor and evaluate care-management plan effectiveness and modify plans as needed
• Collaborate with healthcare providers and pharmacists to drive personalized health management and improve consumer health outcomes

Telephonic Clinical Nurse Coordinator – BioPlus Specialty Pharmacy

Data Analyst

• Oversee automated daily and monthly enrollment file updates
• Oversee the member reconciliation process for assigned markets
• Resolve complex enrollment issues
• Provide process oversight of daily business operations to Enrollment Analysts for assigned markets
• Serve as Subject Matter Expert for Enrollment Operations in assigned markets
• Monitor market-specific Service Level Agreements (SLAs) per contractual requirements
• Escalate issues to management as needed
• Interface with state agencies, Health Plans, and internal departments to investigate and resolve complex enrollment issues
• Participate in market meetings and audits to provide market-specific details regarding enrollment load and reconciliation processing

Enrollment Data Analyst III

Compliance

• Manage and oversee projects, initiatives, regulatory audits or exams, internal audits, accreditations, on-site reviews, and risk assessments
• Plan audits, conduct mock audits and audit training, manage audit evidence preparation, and assess audit preparedness
• Establish project plans, gap analyses, milestone dates, and other significant project aspects
• Provide leadership updates
• Maintain knowledge of laws, regulations, and company strategies to assess impact
• Consult with clients as a subject matter expert
• Conduct complex investigations
• Document findings and ensure corrective actions are completed
• Interface with external clients, regulators, vendors, suppliers, internal stakeholders, and senior management
• Support foundational and strategic compliance responsibilities for the team and management
• Work in a hybrid Ohio-based arrangement with in-office attendance 1–2 days per week

Compliance Manager

Nurse

• Work under the direction and supervision of an RN with overall responsibility for the member's case as required by applicable state law and contract
• Contribute to the LTSS care coordination process within the scope of licensure
• Assist the responsible RN with telephonic or face-to-face assessments
• Identify, evaluate, coordinate, and manage members' physical health, behavioral health, social services, and long-term services and supports needs
• Assist the responsible RN in identifying members at high risk for complications
• Obtain clinical data as directed by the responsible RN
• Assist in identifying members who may benefit from an alternative level of care or waiver programs
• Provide collected information to the responsible RN for verification, interpretation, additional assessments, and care-plan development
• Participate in coordinating care for members with chronic illnesses, co-morbidities, and/or disabilities
• Collaborate with the RN, member, and healthcare team to support cost-effective and efficient utilization of health benefits
• Apply understanding of disease processes, terminology, and clinical guidelines to member needs without requiring nursing judgment
• Travel to client sites, worksites, designated locations, and other locations as required
• Attend office meetings or training occasionally

LTSS Service Coordinator Clinician, LPN/LVN, LSW, LCSW, LMSW

Educator

• Provide health coaching services to disease management program members
• Deliver education, motivational support, and individualized action planning
• Provide information to members eligible for disease management programs
• Conduct telephonic meetings with program members according to program standards
• De-escalate situations with members resistant to health coaching or disease management interventions
• Consult department associates on methods to help members recognize and overcome health barriers
• Increase participants’ motivation by addressing preventative care, barriers, and needs
• Promote incremental behavior change and healthier outcomes
• Conduct behavioral assessments to identify individual knowledge, skills, and behavioral needs
• Coordinate with the multidisciplinary clinical team as needed

Telephonic Health Educator

• Provide health coaching services to disease management program members
• Deliver education, motivational support, and individualized action planning
• Provide information to members eligible for disease management programs
• Conduct telephonic meetings with program members according to program standards
• De-escalate situations involving members resistant to health coaching or disease management interventions
• Consult with department associates on methods to help members recognize and overcome health barriers
• Increase participants’ motivation by addressing preventative care, barriers, and needs
• Conduct behavioral assessments to identify member knowledge, skills, and behavioral needs
• Promote incremental behavior change and healthier outcomes
• Coordinate with others on the multi-disciplinary clinical team as needed

Operations

• Interpret and communicate departmental and organizational policies and procedures
• Receive, validate, and enter information into Finance systems
• Adhere to internal controls and tracking reports for reconciliations and analysis
• Monitor and update controls to ensure compliance
• Conduct independent analysis to resolve complex and varied work process issues

Financial, Accounting Operations Specialist

Pricing Analyst

• Implement new processes, process improvements, and best practices related to guarantee monitoring and ASO pass-back activities
• Create and implement metrics and support performance measures to establish performance objectives for revenue maximization
• Create tools and processes to monitor margin revenue and client retention
• Monitor revenue performing below thresholds and implement necessary tasks to bring performance to or above targets
• Implement pricing in the system related to margin
• Support the Pharmacy Services team in implementing future revenue, member expansion, and growth capacity
• Provide Administrative Services Only (ASO) support functions

Senior Pharmacy Benefit Manager – Pricing Strategy Analyst

Manager

• Manage care for members with complex and chronic care needs within the scope of licensure
• Assess members and develop individualized care management plans
• Implement care plans by facilitating authorizations and referrals
• Coordinate internal and external resources
• Monitor and evaluate care plan effectiveness and modify plans as needed
• Interface with Medical Directors and Physician Advisors on treatment plans
• Negotiate reimbursement rates as applicable
• Assist with provider, claims, or service-related problem solving
• Assist with development of utilization and care management policies and procedures
• Perform duties telephonically or on-site, including hospital discharge planning
• Ensure member access to services appropriate to their health needs

Nurse Case Manager II

Call Center Representative

• Interpret and enter moderately complex prescriptions
• Process prior authorizations
• Troubleshoot adjudication issues
• Verify member information and input data for pharmacists
• Educate members on pharmacy-based rules related to prescriptions and medication resources or assistance programs
• Process prior authorization requests from physicians' offices
• Ensure compliance with Medicare requirements
• Inform relevant parties of prior authorization determinations
• Resolve grievances and appeals issues
• Respond to inquiries from physicians, sales teams, and members about formulary and prescription benefits
• Generate reports relating to rebates, physician utilization, Beers Criteria, Reliance members, and other ad hoc reports
• Maintain records of prior authorizations, rebates, and monthly reports
• Support Medicare, Medicaid, and Commercial member populations through the Clinical Pharmacy Care Center

Pharmacy Technician II – CarelonRx Call Center

Clinician

• Manage members’ cases within the scope of RN licensure
• Provide direction and oversight to non-RN clinicians participating in members’ cases
• Develop, monitor, evaluate, and revise member care plans
• Perform telephonic and face-to-face clinical assessments
• Identify, evaluate, coordinate, and manage members’ physical health, behavioral health, social services, and long-term services and supports needs
• Identify members at high risk for complications and coordinate care with members and healthcare teams
• Manage members with chronic illnesses, co-morbidities, and/or disabilities to support cost-effective utilization of health benefits
• Obtain member histories and develop individualized care plans
• Establish short- and long-term goals with members, caregivers, families, natural supports, and physicians
• Identify members who may benefit from alternative levels of care or waiver programs
• Ensure members’ access to required services
• Facilitate service authorizations and referrals when appropriate
• Interface with Medical Directors, Physician Advisors, and interdisciplinary teams on care management treatment plans
• Assist with provider, claims, and service-related problem solving
• Assign tasks to non-RN clinicians, verify and interpret information they obtain, conduct additional assessments, and review their performance

LTSS Service Coordinator – RN Clinician

• Work under the direction/supervision of an RN with overall responsibility for the member's case
• Contribute to the LTSS care coordination process within the scope of licensure
• Assist the responsible RN with telephonic or face-to-face assessments
• Identify, evaluate, coordinate, and manage members' physical health, behavioral health, social services, and long-term services and supports needs
• Assist the responsible RN in identifying members at high risk for complications
• Obtain clinical data as directed by the responsible RN
• Assist in identifying members who may benefit from an alternative level of care or waiver programs
• Provide collected information to the responsible RN for verification, interpretation, additional assessment, and care-plan development
• Participate in coordinating care for members with chronic illnesses, co-morbidities, and/or disabilities
• Coordinate with the RN, member, and healthcare team to support cost-effective and efficient utilization of health benefits
• Travel to client sites, designated locations, and worksites as required
• Attend office meetings or training occasionally

LTSS Service Coordinator Clinician – LPN/LVN, LSW, LCSW, LMSW

Consultant

• Provide provider relations and network management consulting support to complex, high-profile provider organizations
• Serve as a technical resource and mentor to other consultants
• Support the ACCESS for Adults program
• Lead behavioral health provider engagement, community partnership development, resource coordination, and referral network collaboration throughout Connecticut
• Develop network recruitment and retention strategies to maintain high-quality contracted providers
• Identify, research, and analyze professional provider practice patterns and develop improvement recommendations
• Conduct provider outreach and engagement
• Develop community partnerships
• Deliver educational presentations
• Promote available resources
• Coordinate referral networks
• Conduct community outreach and network development activities throughout Connecticut, including rural communities
• Collaborate with behavioral health providers, primary care practices, community organizations, and other stakeholders to strengthen referral networks, increase program awareness, and improve access to behavioral health services

Network Management Consultant

• Examine and treat patients under the direction of the physician.
• Conduct outreach to members recently discharged from the ER for follow-up and referral to CareBridge services.
• Enroll members into CareBridge services and schedule visits with nurse practitioners.
• Triage members, conduct nursing assessments and refer to an acute nurse practitioner.
• Review patient medical records, interview patients and measure vital signs.
• Explain procedures, perform treatments and administer prescribed medication.
• Facilitate patient transfers to alternate levels of care.