Medica

Manager

• Provide member-centered, evidence-based pregnancy case management across multiple products
• Conduct comprehensive assessments
• Develop, implement, and monitor individualized care plans
• Coordinate services across the healthcare continuum
• Deliver education and care coordination
• Identify gaps in care and advocate for maternal members
• Help reduce pregnancy- and birth-related complications and healthcare costs
• Communicate with physicians and healthcare providers
• Negotiate and access resources
• Support organizational mission, vision, goals, and strategy
• Make decisions under stress while managing multiple complex issues

Pregnancy Case Manager III

• Provide member-centered, evidence-based case management across Medicare Advantage, State Public Programs, Commercial, and Individual and Family products
• Serve members with the highest needs and help them navigate the health system telephonically
• Understand each member's care goals
• Coordinate care across multiple providers
• Assist members with finding community resources
• Reduce illness burden for individuals and families while decreasing healthcare costs
• Ensure members with complex illness are aware of their plan of care
• Ensure providers and Medica care management services are aware of the plan of care
• Establish care management accountabilities and hold resources accountable
• Engage members and provider care teams in care plan discussions
• Engage members and families
• Design and implement targeted programs

Transplant Case Manager IV

Care Coordinator

• Manage a specified caseload of members independently
• Create individualized care plans
• Coordinate approved medical and social services
• Educate members about Medicare and Medicaid benefits
• Serve as a primary contact to address and mitigate member questions and concerns
• Partner with physicians, providers, and county financial entities regarding care plans
• Provide updates on member progress
• Conduct telephonic and in-home member assessments
• Schedule and manage work based on member availability and regulatory requirements
• Travel within the community to meet members in their homes
• Perform other duties as assigned

Care Coordinator II, III – RN, Licensed SW

Claim Processor

• Adjudicate professional and institutional medical claims from initial receipt through final determination
• Process an average of 35 to 50 claims daily while maintaining quality and productivity standards
• Review claims for coding accuracy, pricing, benefit application, eligibility, and payment determination
• Analyze complex claim scenarios involving coordination of benefits, member liability, coinsurance, copays, and balance billing
• Identify and resolve claim discrepancies, system issues, and payment irregularities
• Interpret and apply benefit plans, policies, regulatory requirements, and internal procedures
• Navigate complex claims involving high-dollar amounts, multiple service dates, specialized provider arrangements, and unique benefit situations
• Use critical thinking and sound judgment to determine appropriate claim outcomes
• Escalate issues requiring additional review, coding validation, or medical review
• Collaborate with coders, medical review teams, auditors, analysts, account managers, and operational partners
• Coordinate claim research and issue resolution with internal stakeholders
• Support escalated member, provider, and client issues requiring specialized claims expertise
• Share knowledge and best practices with team members
• Process claims within HealthRules and price claims for WebTPA platforms
• Access external pricing and vendor portals as needed
• Work with network partners and vendors to obtain pricing and claim adjudication information
• Follow established SOPs and workflow documentation to ensure processing consistency
• Meet accuracy, turnaround time, and productivity expectations
• Identify trends and opportunities to improve processes and workflows
• Maintain compliance with departmental policies and regulatory requirements
• Contribute to team goals and continuous improvement initiatives
• Perform other duties as assigned

Claim Processor III

General

• Manage and resolve complex member complaints, grievances, appeals, and some regulatory inquiries
• Independently review and evaluate complex or high-risk cases
• Determine appropriate resolutions in accordance with regulatory, contractual, clinical, and policy requirements
• Route and coordinate clinical and non-clinical case components
• Communicate determinations to members, providers, and internal stakeholders
• Ensure cases meet quality, accuracy, timeliness, and compliance standards
• Maintain thorough, accurate, audit-ready documentation
• Support escalated, high-visibility, and executive-level complaints
• Assist in drafting responses to regulatory agencies such as CMS and state regulators
• Collaborate with cross-functional stakeholders to resolve cases
• Track regulatory timelines and escalate risks
• Interpret complex regulatory requirements, policies, and contractual obligations
• Identify systemic issues, trends, and process gaps
• Recommend and support process improvements
• Provide guidance to peers on complex cases, processes, and documentation standards
• Share casework insights to improve team performance and consistency
• Prioritize workload across competing deadlines and regulatory requirements
• Perform other duties as assigned

Appeals & Grievances Specialist III

Analyst

• Review and code clinical documentation using ICD, CPT, HCPCS, and internal coding guidelines
• Validate coding accuracy for compliant billing, reimbursement, and data reporting
• Research missing or unclear information for proper code assignment
• Complete timely coding reviews supporting accurate claims processing
• Audit claims, encounters, and documentation to detect coding errors or inconsistencies
• Analyze coding patterns to identify trends, risks, and gaps affecting payment accuracy
• Document audit findings and recommend corrective actions
• Communicate audit results to internal partners
• Investigate coding impacts on claims adjudication, reimbursement, and provider disputes
• Collaborate with configuration, operations, and provider teams to resolve coding issues
• Verify coding rules within system logic and flag discrepancies
• Support issue triage workflows
• Apply coding regulations, payer guidelines, and organizational policies
• Maintain regulatory, audit, and documentation compliance
• Participate in coding quality and process improvement initiatives
• Monitor coding rule updates and support implementation of required changes
• Guide junior analysts on coding practices, documentation requirements, and audit methods
• Assist with training, documentation updates, and knowledge-sharing
• Perform other duties as assigned

Coding Analyst II

Auditor

• Audit claims for coding accuracy, benefit payment, contract interpretation, and compliance with policies and procedures
• Gather findings at a macro level
• Make recommendations for process improvements and efficiencies
• Perform professional responsibilities under direct supervision regarding methods and processes
• Perform other assigned duties