• Provide comprehensive leadership and strategic oversight to the benefit charge team, ensuring performance goals, service levels, and quality standards are consistently met while also fostering internal team growth • Oversee daily operations including benefit charge volumes, processing timelines, and quality metrics to maintain optimal efficiency • Lead coaching sessions to foster development, accountability, and continuous improvement while conducting regular 1:1's in addition to mid-year and annual reviews • Ensure all processes comply with internal audit standards and regulatory requirements while overseeing daily operations to maintain optimal efficiency • Represent the team in client meetings and calls, particularly for high-impact accounts or escalated issues • Collaborate with internal teams and clients to improve processes and outcomes while delivering feedback to senior leadership on team performance, client trends, and operational challenges to support strategic planning • Act as the primary escalation point for complex benefit charge scenarios and internal team concerns, offering guidance and resolution particularly for high impact accounts or escalated issues • Bring creative and strategic solutions to complex problems and act as a change agent to evolve processes and team effectiveness • Proactively coordinate with the mailroom and data processing teams to communicate expectations and adjust workload priorities

• Performs care management duties to assess and coordinate all aspects of medical and supporting services across the continuum of care for complex/high acuity populations • Develops a personalized care plan/service plan for long-term care members • Evaluates the service needs of the most complex or high risk/high acuity members and recommends a plan for the best outcome • Develops and continuously assesses ongoing long-term care plans/service plans • Coordinates and manages as appropriate between the member and/or family/caregivers and the care provider team • Monitors care plans/service plans and/or member status • Monitors member status for complications and clinical symptoms or other status changes • Reviews member data to identify trends and improve operating performance and quality care • Collaborates with healthcare providers as appropriate to facilitate member services and/or treatments • Collects, documents, and maintains all member information and care management activities • Provides and/or facilitates education to long-term care members and their families/caregivers • Acts as liaison and member advocate between the member/family, physician, and facilities/agencies • May perform home and/or other site visits to assess member needs and collaborate with resources • Partners with leadership team to improve and enhance quality of care and service delivery for long-term care members in a cost-effective manner • May precept clinical new hires and provide guidance and support in navigating within a Managed Care Organization (MCO)

• Provides strategic leadership for teams performing advanced, complex claim reviews to ensure accuracy, regulatory compliance, and achievement of payment integrity goals. • This role accelerates program growth by analyzing performance trends, standardizing processes, and implementing consistent review methodologies. • Leveraging deep expertise in ICD-10, CPT/HCPCS coding, and clinical guidelines, the manager delivers actionable insights that shape operational strategies and drive informed decision-making. • Monitoring and optimizing business processes to ensure accuracy, compliance, and integrity in billing and claims payment. • Leads and mentors high-performing teams conducting advanced coding and clinical validation reviews. • Develops and maintains standardized documentation that supports business objectives and ensures consistency in review methodologies and outcomes. • Collaborates with cross-functional stakeholders to identify process improvement opportunities and champion innovative solutions. • Establishes and oversees end-to-end audit program lifecycle within Payment Integrity by setting strategic audit direction, managing and developing teams, and ensuring compliance with all regulatory, contractual, and organizational requirements.

• Serve as the primary point of contact and liaison between account management and specialty pharmacy operations • Responsible for facilitating the resolution of specialty pharmacy escalated issues from the account management team's payer clients • Investigate and provide resolution to payer concerns regarding specialty dispenses to members • Analyze and monitor payer complaints to identify trends; develop and implement action plans to maintain high levels of quality service • Collaborate with account management and specialty pharmacy operations departments to investigate and resolve all issues • Expedite urgent orders and follow through to dispense • Document and provide status updates on outstanding issues • Monitor high risk members and prescriptions to mitigate risk • Work with internal teams to enhance processes based on expertise and client insight • Mentor, develop and train newly hired team members as assigned • Performs other duties as assigned • Complies with all policies and standards