Specifically, this position will support the Surest large group work required from a regulatory perspective. Responsibilities include aligning with the business to Run CMS Provided Review Tools prior to large group filings Coordinate tracking/analysis of objections for trending and identification of opportunities for business Project manage assigned implementation work fr

Locate and engage members in the community Partner with NorthStar team to support complex members in the community Conduct screenings face to face or telephonically, to assess social determinate of health needs (SDOH screening tool) Provide information on member needs for community resources to Wellness Coordinator and follow up on referrals received Conduct post discharg

Support the Clinical Program Evaluation and Data Science Team and UHC Value Creation as a data and programming expert Conduct administrative claims (medical and pharmacy claims) extraction and programming of claims based analytic datasets Assist in the development of project specific study protocols (or abbreviated analysis plans) and technical specifications Adhere to al

Lead the design and delivery of large scale data warehouse infrastructure solutions to support enterprise wide reporting, analytics, and data science needs Work with healthcare business stakeholders to identify key business problems, then diagnose, analyze and synthesize advanced data engineering solutions in areas such as local market health plan support; clinical and re

Perform quantitative analysis of actuarial, financial, utilization and costs data to help leaders make decisions Develop pricing methodologies and assumptions Designing and refining pricing tools Develop new rates and prepare cost estimates Prepare quarterly and annual rate filings Assist in the development of financial forecasts and projections Provide input on market st

Collaborate with partners to identify, investigate, and communicate cost and utilization patterns for inefficiencies and potential opportunities in various member populations to help reduce overall total cost of care Seek opportunities to improve processes and identify areas of improvement specifically related to data reliability, efficiency, and quality (implement and sc

Evaluation of member discharge needs including delays in care and readmission prevention plan Collaboration with providers and members to coordinate care post discharge Participate in rounds with the Medical Director to discuss cases as needed Identification of internal or community based program support or resources Coordination with the facility Discharge Planner to ens

Develop & organize the strategic business planning process, gather/provide input, tracking team progress against priorities & objectives Promote advancement of SY Sales Culture framework & systems to modernize the Ohio health plan Help build & deploy a marketing plan that aligns with the strategic business plan (i.e. Small Business Sweepstakes social media campaign) Coord

Determine the appropriateness of inpatient services following evaluation of medical guidelines and benefit determination Identify solutions to non standard requests and problems Translate concepts into practice Act as a resource for others; provide explanations and information on difficult issues It feels great to have autonomy, and there's also a lot of responsibility th

Take inbound calls through the phone queue to assist families access Applied Behavior Analysis (ABA) services. Educate callers on the ABA benefit and Autism in the State of Maryland. Deliver quality customer service, assisting with the referral process Make outbound calls to families to assist with acquiring diagnostic documentation Assist with organizing group email inbo

Design and maintain models from end to end, including building connection to new database, data preparation, monitoring data quality, data scrubbing, building data validations, running data analysis and reporting Develop network pricing and trend tools, business intelligence dashboards and predictive analytical models using modern statistical techniques Understand provide

Locate and engage members in the community Partner with NorthStar team to support complex members in the community Conduct screenings face to face or telephonically, to assess social determinate of health needs (SDOH screening tool) Provide information on member needs for community resources to Wellness Coordinator and follow up on referrals received Conduct post discharg

Identify specific member and provider demographic information Initiating and following up on requests for medical records and responses on behalf of clinicians Preparing quality of care cases for hand off to clinical reviewers (Nurses, MDs) Managing and maintaining quality and productivity metrics You'll be rewarded and recognized for your performance in an environment th

Locate and engage members in the community Partner with NorthStar team to support complex members in the community Conduct screenings face to face or telephonically, to assess social determinate of health needs (SDOH screening tool) Provide information on member needs for community resources to Wellness Coordinator and follow up on referrals received Conduct post discharg

Respond to and resolve, on the first call, customer service inquires and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility and claims, financial spending accounts and correspondence Help guide and educate customers about the fundamentals and benefits of consumer driven health care topics to select the best benefit plan o