CenterWell Senior Primary Care

• Oversee the review, adjudication, and resolution of home health, DME, home infusion and SNF claims, including Medicare, Medicaid, and commercial payer claims, ensuring compliance with payer guidelines, CMS regulations, and organizational policies. • Determine whether claims are paid, denied, returned, or adjusted based on clinical documentation, coding accuracy, authorization status, and payer requirements. • Manage escalated, complex, or high-risk claims issues, including denials, underpayments, and payer disputes. • Manage and develop claims processing professionals and/or claims supervisors; set performance expectations, provide coaching, and conduct performance reviews. • Identify, lead, and implement change initiatives to improve claims processing efficiency, denial rates, turnaround times, and cash flow. • Collaborate with Coding, Clinical Operations, Intake, Authorization, Finance, and Compliance teams to ensure accurate documentation and clean claim submission.

• Oversee clinical operations for the location, including patient care delivery, staff management, documentation quality, and regulatory compliance. • Review referrals, determine admission appropriateness, assign clinicians, and ensure Plans of Care meet patient needs and agency standards. • Guide, support, and educate clinicians; help goal‑set, care planning, and clinical decision‑making. • Ensure clinical documentation, audits, and billing meet Medicare, payer, and company standards. • Participate in hiring, training, performance evaluation, coaching, and corrective action for clinical staff. • Conduct ongoing staff education based on documentation review, utilization review findings, and performance improvement data. • Coordinate communication among physicians, team members, and caregivers to support care coordination, discharge planning, and outcome achievement. • Participate in quality improvement, data tracking, budgeting activities, marketing initiatives, and community relationship development. • Provide direct patient care on a limited basis in exceptional or unplanned circumstances.

• responsible for the accurate and timely dispensing of prescribed medication to patients • ensure adherence to quality assurance standards • make decisions regarding own work methods in ambiguous situations • follow established guidelines/procedures

• Contributes to administration of utilization management • Works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems • Receives assignments in the form of goals and determines approach, resources, schedules, and goals • Provides non-clinical support for the procedures ensuring best treatment, care or services for members • Makes decisions related to resources, approach, and tactical operations for projects and initiatives involving own departmental area • Requires cross departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with other managers across the department

• Conducts selling activities within a primary care setting • Makes 45 outbound calls per day with the goal of getting patients back into clinics • Re-engages Medicare eligible patients through telephonic conversations • Proactively anticipates patients' needs in order to provide guidance and customer service • Documents and modifies contact notes across multiple systems as necessary

• Produce and maintain ACO reporting package including performance reporting for ACO Medicare programs (e.g., MSSP, LEAD, ACCESS, etc.) • Analyze ACO datasets and claims files to identify trends and compare against CMS benchmarks and targets • Partner with Operations, Finance, and Clinical teams to translate data findings into actionable insights and performance improvement opportunities • Support financial and quality analyses related to shared savings, total cost of care, utilization trends, and quality measure performance • Validate data accuracy and completeness across multiple data sources; ensure integrity of ACO program data; work with Data Analytics team on issue resolution • Partner with Data Analytics team to develop dashboards and visualizations to communicate trends, risks, and opportunities for ACO leadership and key stakeholders • Leverage data to automate business processes supporting care coordination, attribution / alignment, network management, and other operational workflows • Possesses strong SQL skills / ability to query data; has experience working with data editing environment, Snowflake • Stay current on CMS program requirements, ACO regulations, and value-based care metrics impacting Original Medicare programs • Coordinate the timely production and submission of reports per the specifications and timetables established by external bodies and internal leadership. Ensure reports are distributed or are available to stakeholders, teams, committees, etc. that would likely benefit from the information. • Advise on design of meaningful, insightful, compelling data formats for the effective communication of information, customized to target audience(s). • Present information on conference calls, web meetings, in-person meetings, and other group communication methods.

• Leverages targeted geographic analysis to engage with Physician offices • Influences physicians to route patients' specialty drug prescriptions to Humana Specialty Pharmacy for fulfillment • Focuses on increasing orders to Humana Pharmacy, resulting in increased prescriptions and revenues • Spends time building relationships on front office to back office medical clinic sales calls within the territory • Provides staff education and information on options for patient use of Specialty Pharmacy medications

• Collaborate with leadership to develop policies, procedures and methods to check operational quality and improve same. • Identify areas of opportunities and escalate to leadership in areas such as quality improvement, process management and reliability science. • Maintain communications with leadership regarding quality assurance activities. • Begin to influence department's strategy. • Make decisions on moderately complex to complex issues regarding technical approach for project components, and perform work without direction. • Work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. • Exercise considerable latitude in determining objectives and approaches to assignments.

• Provide high-quality support to healthcare providers contacting the call center to initiate referral authorizations or check the status of existing requests • Serve as a key liaison between providers and internal UM teams, ensuring timely and accurate processing of referral and authorization inquiries in accordance with organizational policies and regulatory guidelines • Provide non-clinical support for the policies and procedures ensuring best and most appropriate treatment, care or services for members • Respond promptly and professionally to incoming calls from providers • Accurately gather, verify, and enter provider and member information into the appropriate systems • Review and process referral authorization requests according to established UM protocols, policies, and regulatory requirements • Collaborate with clinical and administrative staff to resolve issues, clarify requirements, and ensure efficient case management • Provide clear, concise, and courteous information regarding UM processes, documentation requirements, and referral guidelines • Monitor call queues and manage multiple tasks to maintain service level agreements and minimize provider wait times • Identify and escalate complex or urgent cases to the appropriate clinical or supervisory staff as needed • Maintain thorough documentation of all interactions and transactions in accordance with company standards • Participate in ongoing training and quality assurance activities to maintain up-to-date knowledge of UM policies and procedures • Adhere to all applicable privacy, confidentiality, and compliance regulations

• Develop, maintain, and optimize Power BI dataflows, dashboards, and visuals. • Schedule and monitor dataset refreshes to ensure accurate reporting. • Aggregate, standardize, and reconcile data from multiple internal and external learning sources. • Monitor and troubleshoot API integrations and automated ETL processes, resolving issues and validating results. • Investigate and resolve data discrepancies by applying reconciliation and equivalency logic to learner records. • Build user-friendly interfaces and visualizations to make data accessible, understandable, and actionable for a variety of stakeholders. • Administer user access and security groups across Power BI environments. • Collect and analyze learning metrics from past training sessions. • Identify performance gaps and support audits of technology solutions, including data warehousing and Power Platform visualizations. • Monitor and evaluate training program metrics, connect learning outcomes to on-the-job performance statistics and KPIs, and assess the impact of learning initiatives on business unit outcomes to prepare insights for leadership. • Partner with business unit leaders and other stakeholders to report on training program metrics and outcomes. • Support audits and ensure compliance reporting. • Partner with stakeholders to plan for future interventions and continuous improvement of learning strategies.