Excellus Health Plan Inc.

Job Description: Summary: The Transition Coordinator will work in support of the Hospital to Home program by coordinating efforts of medical and behavioral health care managers to ensure that all members who are hospitalized leave with comprehensive discharge plans. The Care Coordinator may engage members and/or their loved one's face to face in one of our Hospital to Home facilities and may collaborate with hospital treatment teams and discharge planners. Engagement may also occur over the phone and through electronic channels such as email, Microsoft Teams and fax. Outreach may include but is not limited to: appointment setting, member communication about gaps in care and preventive health opportunities, member and provider education, communication campaigns, prior authorization process for step down treatments, home care, durable medical equipment and medications. The Care Coordinator will assist with mail processing, materials organization, technology/service requests...

Job Description: Summary: The Database Administrator will provide enterprise-wide administration and production support for corporate databases. This position will be responsible for installing, testing, configuring, monitoring, performance tuning, security, and developing evaluation plans, education programs, corporate policies, and procedures. This role will demonstrate a high-level of responsibility and consistency by contributing to the timely response and closure of incidents received via the corporate incident tracking system. The Database Administrator will work to identify functionality to empower users. This key individual frequently interacts with multiple departments to advocate for customers' projects and incidents and providing timely responses. Essential Accountabilities: Level I • Plans, tests and implements new database software releases, patches, upgrades, maintenance, or enhancement initiatives. • Monitors and manages existing systems to provide...

Job Description: The Pharmacy Analytics Consultant provides direct support for both Pharmacy and Medical Drug information needs using a variety of analytic tools and applications. The Consultant will work with internal and external stakeholders and management, as required, to achieve Pharmacy Markets strategy, growth, compliance, and affordability objectives across the enterprise. The analyst collaborates with a multidisciplinary team (e.g., clinical, financial, sales, and Line of Business Leaders) to recommend actionable items leading to positive pharmacy financial performance. This position prepares and presents information to enable both senior management and our customers to better understand, evaluate, and support their goals. Essential Accountabilities: Level I Perform research on projects and manage and lead projects to successfully meet business objectives from across the enterprise. Analyzes data to determine business problem, trends or opportunities for...

Job Description: Summary: The Document Solutions team focuses on the design and creation of correspondence and transactional statements using various software programs. The Publishing Systems Engineer operates in a business analyst/document-generation specialist role as part of the Document Solutions team. This role focuses on programming within the various systems utilized by our Solutions Team. Essential Primary Responsibilities/Accountabilities: Level I: Develops code; analyzes, researches, and resolves system issues for electronic publishing-related problems. Creates, maintains, and follows all documented processes and standards. Builds new and updates existing workflows and documents using xml and text data in variable data composition systems based on the requirements and functional specifications. Documents functional specifications and solutions for work to be performed. Develops or assists in the development of systems testing and implementation plans. Reviews...

Job Description: Summary: Conducts case management program activities in accordance with departmental, corporate, NYS Department of Health (DOH), Centers for Medicaid & Medicare Services (CMS), Federal Employee Program (FEP) and National Committee for Quality Assurance (NCQA) accreditation standards, as appropriate to the member's case assignment. Uses a systematic approach to identify members meeting program criteria; assessing for opportunities to educate, support, coach, coordinate care and review treatment options, through collaboration with providers and community-based resources. Participates in a cross functional, multi-disciplinary team to identify and implement member-centric interventions to ensure optimal and cost-effective health outcomes. Collaborates with interdisciplinary care team to develop a comprehensive care plan to identify key strategic interventions to address member's needs, health goals and mitigate health care cost drivers. Essential...

Job Description: Summary: This position assists the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. This role supports the HARP line of business. Essential Accountabilities: Level I Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities. Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services. Supports effective implementation of performance improvement initiatives for capitated providers. Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate,...

Job Description: Summary: The Manager of Accounting & Financial Reporting is responsible for designing, implementing and maintaining appropriate policies and procedures to ensure accurate and timely monthly, quarterly and annual financial reporting, which is compliant with GAAP, Statutory (STAT) and other regulatory requirements including accurate and timely processing of financial data for the organization and the creation of complete and accurate financial reports for internal and external purposes. This individual utilizes strategic thinking, management techniques and analytical know-how to define business requirements and drives the Accounting and Financial Reporting teams toward "best in class" procedures and processes, ensuring that functional deliverables are achieved. Essential Accountabilities: • Ensures the complete, accurate and timely processing of financial data and reporting for the Health Plan and subsidiaries. Reviews internal and external monthly,...

Job Description: Summary: This role provides the vision, strategy, functionality, and technology solutions for creating and maintaining distributed platforms for both public and private cloud infrastructure-based solutions. This entails the design and use of flexible platforms that deliver features, functionality, and services compatible with industry-leading providers while allowing legacy systems to interact safely when required. This position requires the necessary skills to provide technology research, evaluation, development, and delivery in support of infrastructure deployment solution lifecycles. This position collaborates with the Information Technology teams to lead the organization toward the deployment of technologies that may include PaaS, SaaS, hosted, and on-premises solutions - which will allow for flexible, secure, on-demand cloud-like functionality and services while endeavoring to provide resiliency and achieve cost reduction, while maintaining a highly...

Job Description: Summary: Conducts case management program activities in accordance with departmental, corporate, NYS Department of Health (DOH), Centers for Medicaid & Medicare Services (CMS), Federal Employee Program (FEP) and National Committee for Quality Assurance (NCQA) accreditation standards, as appropriate to the member's case assignment. Uses a systematic approach to identify members meeting program criteria; assessing for opportunities to educate, support, coach, coordinate care and review treatment options, through collaboration with providers and community-based resources. Participates in a cross functional, multi-disciplinary team to identify and implement member-centric interventions to ensure optimal and cost-effective health outcomes. Collaborates with interdisciplinary care team to develop a comprehensive care plan to identify key strategic interventions to address member's needs, health goals and mitigate health care cost drivers. Essential...

Job Description: Summary: This position is primarily responsible for the overall management of strategic and national accounts. This includes but is not limited to acting as a strategic advisor to support clients in the decision making process relative to benefit design, financial impacts, member experience, and industry trends. This role will focus on account retention activities and could expand to include prospecting of new business opportunities. Essential Accountabilities: Level I • Responsible for sales activities, including retention, prospecting, and cross-selling. • Establishes, develops, and maintains positive business relationships with clients, brokers, and internal department contacts. • Develops a thorough understanding of clients strategic goals, financial position and opportunities to offer solutions that meet their needs and ensure overall satisfaction. • Provides oversight for all activities that surround client solutions, operational efficiencies and...

Job Description: Summary: Under the guidance of the Clinical Pharmacists, other clinical team members and divisional management, this position supports and participates in a wide range of provider, customer and staff initiatives/programs including Utilization Management; Quality/Disease Management; Drug Utilization Review; Staff, and customer service support/training. The incumbent also provides administrative support to current processes, as needed, in order to maintain operational efficiencies for clinical-based Prescription Drug Management programs across all regions. Supports Drug Information Services and other specific clinical initiatives participation and management, as determined. This position works as part of the clinical team to improve the appropriateness of provider prescribing patterns and our members' use of medication by conducting concurrent/retrospective and prospective prescription drug utilization analysis; evaluating and making determinations on drug...

Job Description: Job Description Summary: This position plays a critical role in advancing the sales pharmacy strategy across Excellus Health Plan. The incumbent is responsible for driving pharmacy growth, client retention, and margin optimization through strategic partnerships, broker and consultant engagement, industry-facing leadership, and scalable pharmacy education. Serving as a trusted advisor internally and externally, this position bridges sales strategy, broker advocacy, and market intelligence to support the organization's pharmacy value proposition. The manager leads initiatives that support new business acquisition, client renewals, account growth, and long-term retention aligning solutions within the evolving dynamics. This is a highly visible role that trains and enables Sales teams, clients, brokers, and consultants on pharmacy. The incumbent serves the organization as a pharmacy thought leader and collaborates closely with the Pharmacy clinical team, Sales,...

Job Description: Summary: This position supports the Utilization Management (UM) workflows by providing administrative support and customer service. This position acts as a resource for both internal and external customers through completing timely and accurate inbound and/or outbound calls, creating authorizations via phone, Care Advance Provider Tool, and fax for inpatient and outpatient procedures, behavioral health, and durable medical equipment. Essential Accountabilities: Level I Facilitates inbound and outbound calls to customers (members and providers) by delivering excellent customer-centered service providing information regarding services in a call center environment. Responds to customers in a professional, efficient manner to encourage public acceptance of products, services, and policies. Perform triage for UM Services. Serves as the primary contact for providers regarding authorization requests. Contacts members and providers concerning regulatory...

Job Description: Summary: The Software Engineer is responsible for working on projects that are currently being visualized or developed by our organization. This role will be involved with the Software Development Life Cycle methodology and framework, directing software system validation and testing methods, as well as directing software programming initiatives. This position works closely with clients and cross-functional departments to communicate project statuses and proposals. Essential Accountabilities: Level I • Develops code, analyzes, researches, and resolves associated system issues. • Participates in on-call production support rotation. • Supports, maintains, creates and follows all documented IT processes and standards, application documentation and design and code reviews. • Collaborates and communicates with team members and associates throughout the business to understand requirements and identify application impacts. • Creates individual work plans,...

Job Description: Summary: Under the general direction of the Assigned Management, and in accordance with sound and ethical procedures, objectives and controls, a Network Services Analyst analyzes and evaluates the composition and characteristics of Health Plan provider networks. This position also is responsible for the development of consistent payment methodologies and negotiates allowances for out of area/out of network non-par claims. In the course of this work, the Analyst will be required to work closely with others to assemble and produce documentation and informational materials that will guide Senior Management in making strategic network specific business decisions. Essential Primary Responsibilities/Accountabilities: All Levels - Manages and supports various projects with implications for all lines of business. These projects arise in response to shifts in marketplace dynamics, changes in the delivery of healthcare services, or the emergence of new products....

Job Description: Summary: Under general supervision of the Assigned Management, this position is responsible and accountable for the management of pharmacy finance analytics, reporting, and pricing strategy to support the attainment of corporate growth and margin targets for the Pharmacy Line of Business. This position oversees a team which partners with Sales, Underwriting, Actuarial, and PHE to provide analytical guidance, financial oversight, and a comprehensive strategy to support the financial performance of the pharmacy P&L. This individual may assume key project roles and/or manage tasks as required or assigned by senior management. Essential Accountabilities: • Oversees the supervision of assigned personnel, which includes but not limited to recommendations for hiring, release, and promotions, performance evaluation, training, work allocation, training, and problem resolution; evaluates performance and makes recommendations for personnel actions; motivates...

Job Description: Summary: The Manager, IT Computing Operations is responsible for overseeing the daily operations, maintenance, and strategic planning of the organization's data center infrastructure. This role ensures high availability, performance and security of mission critical systems while coordinating with cross functional departments especially Facilities for power and HVAC projects. This includes 24x7x365 management of computer operations team activities and scheduling. This position will also have responsibility for understanding business strategy and incorporating data center requirements into day-to-day initiatives to meet future business demand. Essential Accountabilities: Oversees a 24/7 data center operations, ensuring uptime, balancing power distribution, reliability and performance of systems. Provides a single point of contact and escalation for the overall production computing environment. Establishes standards for data centers; including capacity...

Job Description: Summary: Under the guidance of Risk Adjustment leadership, this position is responsible for delivering multiple concurrent Risk Adjustment Projects and Programs with quality, to plan, and within budget. The Risk Adjustment Project Manager is responsible for all aspects of the project from initiation to post-implementation monitoring and maintenance. This will include developing communications and presenting to internal and external audiences. Manages risk adjustment projects as assigned. In addition, the Project Manager will govern and provide oversight of assigned vendor partners within the Risk Adjustment Program Portfolio to ensure vendor performance meets contractual and Health Plan needs. Conducts operational process analysis and process improvement identification and recommendations and executes action plans. Responsible to fill one or more roles (simultaneously if needed) on Maintenance of Business (MOB) project teams (e.g., program manager, product...

Job Description: Summary: The IT Platform Administrator acts as a liaison between the business and technical resources by ensuring the availability and successful operation of applications for users. This individual will demonstrate a high-level of responsibility and consistency by timely monitoring, responding, and troubleshooting of incidents, installing, upgrading, and maintaining application currency. This position will work to identify functionality to empower users through self-service and automation of relevant tasks. In addition to operating as application support, the IT Platform Administrator will perform periodic audits and maintain application compliance. The Administrator also frequently interacts with multiple departments to advocate for stakeholders' and platform best interests. Essential Accountabilities: Level I • Installs, configures, troubleshoots, patches, and maintains enterprise software platforms for applications to achieve reliable, highly available,...

Job Description: Summary: The Risk Adjustment Project Coordinator supports the risk adjustment initiatives for Excellus Health Plan. Essential Primary Responsibilities/Accountabilities: Level I: Review, monitor and track the medical record retrieval reports to identify provider issues such as but not limited to, refusals to comply with medical record requests. Initiate outbound phone calls to noncompliant providers to resolve provider refusal and/or concerns related to the Health Plan's request for medical records. Builds and maintains strong working relationship with providers and office staff. Educate providers of their contractual obligation to comply with Health Plan's request in a professional manner to minimize provider abrasion. Directly negotiates with providers to procure scheduled commitment to deliver requested medical records, retrieval method, and payable fees for the medical records. Identify and escalate program related issues to the Project Manager...