Avēsis

• Leverage your dental clinical expertise to review dental x-rays and documentation, assessing medical necessity for prior authorizations. • Perform initial reviews of medical necessity cases, ensuring they comply with member eligibility and the covered services outlined in each client contract. • Conduct reviews of prior authorizations by providers, determining cases of recommended treatment in accordance with Avesis UM procedural guidelines. • Document approval decisions for treatment in accordance with prescribed UM department procedural guidance, and forwards applicable files to the client health plan as required by each contract. • Maintain effective intradepartmental communications and actively participate in routine departmental meetings.

• Responsible for the operational leadership, performance, and development of the Account Management team. • Provides day-to-day supervision, coaching, and support to ensure consistent service delivery. • Partners closely with Sales, Underwriting, Finance, Customer Service, Claims, Compliance, and other departments. • Serves as the primary escalation point for the region while promoting accountability and continuous improvement. • Provides strategic oversight for key accounts and large group implementations. • Manages a portfolio of employer groups with more than 150 cardholders. • Coaches employees, monitors workloads, and resolves escalated issues. • Reviews regional performance metrics and conducts performance coaching. • Works remotely while traveling throughout an assigned territory for client meetings, broker visits, and other events.

• Prepare and review underwritten packets. • Track daily incoming and outgoing renewals. • Manage email correspondences of renewal questions. • Process monthly rates and conduct regular audits for specific needs. • Maintain database accuracy in Smartsheet and Cadence. • Communicate closely with Underwriting and Account Management teams. • Conduct comprehensive, regular audits of projects, tasks, and documentation for accuracy.

• Responsible for the strategic leadership and operational execution of People Operations, Total Rewards, HR compliance, and HR technology governance. • Oversee HR Operations and HRIS resources and serves as the primary leader responsible for ensuring scalable, compliant, and efficient people processes. • Partner closely with executive leadership to drive employee experience, operational effectiveness, cost management, and organizational capability. • Provide leadership and oversight for the organization's people infrastructure, including HR Operations, compensation, benefits, compliance, and HRIS governance. • Ensure efficient delivery of HR services, maintaining regulatory compliance, optimizing technology and processes, and developing scalable programs that support both employees and business objectives. • Lead continuous improvement efforts, manage key vendor relationships, develop internal capabilities, and partner across the organization.

• The Appeals and Grievances Coordinator is the primary point of contact for members, providers, and clients throughout the appeals and grievances process. • Provide timely, accurate, and compliant resolution of dental and vision A&G cases within a regulated managed care environment. • Responsible for the completion of appeals and grievances from all states. • Perform reviews of member and provider appeals and grievances for dental and vision waiver services. • Analyze medical records, supporting documentation, and applicable guidelines to make informed decisions. • Document rationale clearly and accurately in alignment with organizational and regulatory standards. • Work closely with clinical teams as well as other internal operational areas to resolve complex cases. • Communicate outcomes effectively to members and providers. • Review and complete all provider appeals and grievances within required timeframes. • Review and complete member appeals and grievances within required timeframes. • Apply Avesis policy, plan documents and/or state guidelines when processing appeals or grievances. • Issue administrative denials appropriately. • Refer denials based on medical necessity to appropriate clinical staff. • Collaborate with appropriate stakeholders to prepare all requests for Independent External Review when required. • Participate in training programs to maintain functional expertise. • Draft formal correspondence such as acknowledgement and resolution notices.

• Responsible for selling commercial vision programs to employers in a specific geographic territory. • Drive new business growth and maintain sales goals. • Develop, manage, and expand distribution partner relationships for commercial vision and/or dental products. • Identify and pursue new sales opportunities within assigned territory. • Prepare, present, and deliver competitive proposals and bid responses to employer clients. • Coordinate cross-functional resources—including Sales, Account Management, Operations, Support, Finance and Senior Leadership—to achieve account objectives. • Generate accurate monthly sales and activity reports. • Collaborate with Account Management and Implementation teams to ensure smooth new client onboarding.

• Selling commercial vision programs to employers in a specific geographic territory. • Driving new business growth by selling ancillary benefits to Small and Mid-Group customers. • Developing, managing, and expanding distribution partner relationships to generate RFPs and bid opportunities for commercial vision and/or dental products. • Identifying and pursuing new sales opportunities within assigned territory to meet or exceed revenue and growth targets. • Preparing, presenting, and delivering competitive proposals and bid responses to employer clients. • Serving as the primary point of contact between prospects, clients, and internal teams throughout the sales lifecycle. • Focusing on retaining and expanding existing client relationships by identifying cross-sell and up-sell opportunities.

• Coordinate all aspects of regulatory and client audits (i.e., pre-site deliverables, mock audits, on-site visits, logistics, and written responses to audit reports and corrective actions) and coordinate across times to document and track completion to ensure audit success. • Synthesize audit-related information (i.e., scope, findings, recommendations, corrective action plans, and status) and provide Compliance and business operations leadership written and oral reports of ongoing and completed audits. • Simultaneously manage multiple audits and collaborate across multiple business areas to communicate gather necessary information within assigned due dates. • Develop compliance communications. • Problem solve and work closely with business partners on issue resolution. • Research, understand, and articulate regulatory and contractual requirements. • Educate business partners on regulatory audit processes as needed. • Manage, track and report data related regulatory and client audits and CAPs. • Coordinate with Legal Counsel as needed. • Perform additional duties as requested or required by management.

• Answer 40-60 inbound calls, responding to inquiries ranging from routine to moderate complexity. • Capture member information accurately and update systems with complete and concise data. • Ensure flexibility, stay organized, and comply with constantly changing programs and business rules. • Investigate issues that cannot be resolved at the time of initial call. • Collaborate with internal teams to research and follow up with the Member until a resolution occurs.

• The EiPaaS Developer role resides within the Operations department and is responsible for overall ownership of the EiPaaS application (Bridgegate) and its environment. • Ensure the accurate, timely, and compliant processing of 834 electronic files, provider files, and other items processed through the EiPaaS/Bridgegate application, while maintaining enterprise-wide oversight of all Bridgegate workflows. • Manage end-to-end processing of HIPAA-compliant healthcare EDI transaction sets, including 834 enrollment files and familiarity with 837 claims and 270/271 eligibility transactions. • Build, configure, and maintain templates for new 834 electronic files as business needs evolve. • Monitor all EiPaaS/Bridgegate workflows, not limited to 834 transactions. • Design and implement comprehensive logging, alerting, and monitoring processes to capture EDI transaction logs, metadata, and automated alerts for data processing anomalies. • Serve as the primary point of contact for all EiPaaS related issues. • Maintain detailed documentation for templates, workflows, transaction logic, and monitoring controls.