ProgenyHealth, LLC

• The Case Manager will focus on empowering the members’ family to support optimal wellness while advocating for the necessary medical services across the health care continuum. • Works in a telephonic managed care setting combining strong clinical knowledge and critical thinking to facilitate a plan of care that will ensure quality medical care for the high-risk member population serviced by ProgenyHealth based on the CMSA national standards for case management practice.

• Analyze claims and EMR data to evaluate program performance, including cost, utilization, and clinical outcomes • Support development of ROI analyses and performance reporting for clients and prospective clients • Build and maintain recurring and ad hoc analyses, ensuring accuracy and clarity of results • Translate business questions into structured analyses with guidance from the Director • Identify trends, outliers, and key drivers within healthcare data and clearly communicate findings • Partner with clinical, client success, and internal teams to support decision-making and continuous improvement • Contribute to the development and standardization of reporting, data processes, and analytical approaches • Prepare clear, concise summaries and presentations for internal and external stakeholders

• Analyze claims and EMR data to quantify the clinical and financial impact of ProgenyHealth programs, including cost, utilization, and outcomes • Develop and communicate clear, credible ROI narratives for clients and prospective clients • Partner with clinical, client success, and growth teams to identify where the program is succeeding and where improvement is needed • Translate ambiguous business questions into structured analyses and actionable insights • Build and standardize analytical approaches, reporting, and data processes from the ground up • Serve as a subject matter expert on healthcare cost drivers, reimbursement methodologies, and Medicaid populations • Present findings to internal leadership and external stakeholders, including clients and prospects

• Lead the identification, definition, and documentation of solution architecture, technical design, and interface requirements • Design end-to-end healthcare interoperability solutions, translating requirements into scalable architecture • Define architectural patterns, integration approaches, and technical standards • Create and maintain architecture artifacts including: Solution architecture diagrams, Data flow and system integration diagrams, Interface specifications and technical documentation • Design and implement integrations using: HL7, FHIR, X12, CCDA, and EDI standards • Develop and support FHIR APIs and RESTful web services • Act as a liaison between clients, product teams, engineering, and business stakeholders • Provide architectural oversight for production interoperability solutions • Troubleshoot complex interface and data exchange issues • Monitor integration performance and recommend improvements

• Lead all aspects of client operations and engagement • Act as the primary advocate for health plan clients • Coordinate and drive meetings connecting us to clients’ needs and goals • Facilitate discussions ensuring every voice is heard • Document actionable steps and share insights • Analyze and organize client change requests for seamless execution • Build strong relationships with client leaders and teams • Handle contracts, systems, and performance guarantees confidently • Champion our services and value proposition • Develop and present client-facing materials • Ensure high-quality client-specific reporting • Take decisive action and escalate issues as needed to protect clients’ interests.

• Independently develop and execute strategic plans, including comprehensive relationship management strategies. • Lead Maternal and Infant Health business consultations, conduct operational reviews, and present annual ROI in business reviews. • Drive retention and cross-sell expansion for your assigned portfolio of clients (5-7 accounts). • Take ownership of processes to ensure exceptional service delivery and compliance with all contract requirements. • Build and maintain close relationships with clients and clinicians (MDs, RNs, CMs, etc.), independently understanding their environments, missions, and initiatives within health plans and across states. • Analyze and present clinical Key Performance Indicators to clients with confidence and clarity. • Demonstrate a deep understanding of all ProgenyHealth services and our value proposition, and communicate this effectively to clients. • Plan, organize, and lead strategic client events such as quarterly and annual meetings as a true individual contributor. • Utilize your expert problem-solving skills to work both independently and collaboratively within teams when needed.

• Assesses the physical, functional, psychological, environmental, educational, and financial needs of members referred to the Case Management program. • Completes needs assessments for all members in CM and develops care plans individualized to the needs of each member as per ProgenyHealth policies and procedures. • Assigns risk stratification based on complexity of medical and social needs and determines ongoing frequency of calls to continually assess plan of care. • Monitors the care plan to ensure effective, appropriate provision of services and adequacy of benefits. • Interfaces with providers to assist with care coordination activities, which can include appointments, transportation, DME, etc. • Provides education to members regarding condition, treatment plan, benefits, services, and how to access needed care. • Monitors ongoing progress towards goal achievement and reassess changes in health status throughout continuum of care. • Provides referrals to appropriate community resources; facilitates access and communication when multiple services are involved; monitors activities to ensure that services are actually being delivered and meeting the needs of the member. • Participates in interdisciplinary and client rounds with pertinent health care team members to identify, clarify, and/or prevent risk, quality, or plan of care variances.

• Assist the Case Management department in the administration of CM functions • Conduct telephonic outreach to members and monitor their eligibility • Update database information and research support services for families • Support Case Managers by developing communication with members • Document member and provider information in medical management database • Complete scripted introduction calls to Provider offices • Transfer questions of a clinical nature to Nurse Case Manager • Attend and participate in Quality Improvement meetings and training sessions

• The Clinical RN Chart Reviewer will perform clinical reviews of medical records and other documentation to validate issues of claims coding accuracy, medical necessity, and the appropriateness of treatment settings and services delivered. • The Clinical RN Chart Reviewer will report to the Payment Assurance Manager and support a culture and work environment that promotes and inspires an active, continuous improvement philosophy regarding products and services in line with our company mission. • Responsibilities will include: • Audits and analyzes neonatal intensive care unit (NICU) claims according to ICD-10 coding principles and clinical guidelines. • Analysis of claims data to optimize reimbursement by ensuring that the diagnosis codes, procedure codes, and supporting documentation accurately support the service rendered. • Ensures claims analysis complies with ethical coding standards, guidelines, and regulatory requirements. • Responsible for performing clinical reviews of medical records and other documentation to validate issues of claims coding accuracy, medical necessity, and the appropriateness of treatment settings and services delivered. • Utilize Clinical Review Tools and EMR Systems. • Research reimbursement regulations for claim payment compliance to support and validate audit findings. • Assist with the development of claims audit process documentation, including workflow diagrams, policies and procedures, and standard operating procedures. • Detect discrepancies in provider billing and recommend adjustments to ensure proper reimbursement.

• The Social Worker will work in conjunction with the Nurse Case Managers, coordinating care of the high-risk newborn population served by ProgenyHealth based on the CMSA national standards for case management practice. • The Social Worker will demonstrate strengths in working independently as well as collaboratively within a team environment. • An understanding of ProgenyHealth goals and outcome measures is important to the accountability of the Social Worker and the success of the member-focused Specialty Care Management Programs. • Focus on empowering the caregiver and family to support optimal wellness while advocating for the necessary services and community resources across the health care continuum. • Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, least restrictive level of care. • Build and maintain relationships with caregivers and healthcare providers to develop an individualized plan of care that is member focused and addresses physical and psycho-social barriers to optimal outcomes. • Identify any impediments to member progress and advocate for patients and families as needed to ensure the patient's needs and choices are fully represented and supported by the healthcare team.