Job Details Working under the direction of the Vice President, with minimal supervision, negotiates hospital and health system agreements, including associated physician and ancillary agreements, in building and maintaining high-quality and cost-effective provider networks to meet and exceed regulatory and organizational goals. Develops and maintains written contracts and analyzes hospitals and systems for reimbursement rates and contract languag...
Job Details Works under general supervision and answers calls from physician and pharmacy providers through pharmacy hotline. Assist in administering prior authorizations according to established guidelines and assists Clinical Pharmacists in case review process. Actively participate in physician education and outreach program and perform claims analysis for drug utilization review (DUR), fraud, abuse, and over-utilization. Job Description Please...
Job Details Works under the general supervision of the Provider Appeals Team Lead and Provider Appeals Manager to prepare and manage the Inpatient Services appeals throughout the Appeals Process. The position is responsible for receiving, processing, routing, and monitoring provider inpatient appeals at each step of the appeals process and assuring timely resolution of those appeals. Position exercises attention to detail, ability to manage multi...
Job Details Works with minimal supervision to ensure that comprehensive, quality, cost effective patient care is offered for members in need of care coordination. Review medication profiles, verify appropriate testing, and facilitate office visits with primary care and specialist physicians for members targeted for care coordination services. Coordinate with hospital case managers to ensure continuity of care and outpatient services when medicall...
Job Details Works with minimal supervision to ensure that comprehensive, quality, cost effective patient care is offered for members in need of care coordination. Review medication profiles, verify appropriate testing, and facilitate office visits with primary care and specialist physicians for members targeted for care coordination services. Coordinate with hospital case managers to ensure continuity of care and outpatient services when medicall...
Job Details Working under the general supervision of the Manager of Provider Reimbursement, perform contract configuration and financial analysis for managed care contracts. In addition, generate monthly reports of revenue trends and performance statistics. The position requires sophisticated managed care analytical skills and configuration experience. The position is responsible for maintaining payment accuracy as defined by negotiated contracts...
Job Details Serve as the primary point of contact and operational lead responsible for managing the procurement, administration, and ongoing performance of Pharmacy Services for members of JHP and HPP Oversee contractual, financial , operational, clinical and quality aspects related to pharmacy benefits, ensuring alignment with business objectives and regulatory compliance. Provide strategic and operational oversight to optimize pharmacy benefit ...
Job Details The Vice President of Customer Experience (CX) leads a member-focused strategy across Medicaid, Medicare, ACA, CHIP, and MLTSS, overseeing customer service operations and the member call center. This role drives service excellence through multi-channel engagement, process improvement, and evidence-based onboarding. The VP ensures regulatory compliance, equitable access, and cultural responsiveness while aligning cross-functional effor...
Job Details We are seeking a Chief Actuary to lead the actuarial strategy and execution across our government-sponsored health programs, including Medicaid, Medicare, CHIP, and ACA. This executive will serve as a key member of the leadership team, responsible for driving pricing strategy, reserving accuracy, and trend analytics that support sustainable growth and financial performance. The ideal candidate will bring deep technical expertise, a st...
Job Details Manage a team responsible for credentialing/recredentialing of practitioners/providers following NCQA and regulatory standards, maintenance of the provider credentialing database and reporting function. Job Description Essential Functions: Proficient in credentialing software, databases and Microsoft Office Suite. Ensure that JHP/HPP/Enterprise, NCQA, Federal, State and other regulatory requirements are met. Monitor team production an...
