The Health Plan jobs in Wheeling, WV - 28 jobs

The Behavioral Health Medical Director position at The Health Plan (THP) involves providing clinical guidance to the Behavioral Health Care Coordination and Utilization Management teams. Key responsibilities include facilitating integrated BH rounds, making clinical coverage determinations, maintaining clinical integrity, and ensuring compliance with evidence-based guidelines. The role requires collaboration with various clinical professionals and leadership teams, focusing on recovery-oriented and cost-effective care.This will be a Dyad relationship with the Directors and VP's of the Clinical Services Department. Required: * MD/DO with board certification in Psychiatry, with qualifications in Addiction Psychiatry or Medicine. * A West Virginia and Ohio Physician License is required. Or willingness to obtain them witin 90 days. * A minimum of three years of clinical experience beyond residency/fellowship is necessary, with supervisory and teaching experience preferred. * ASAM Certification is required. Desired: * Basic computer literacy. * Prior leadership roles while in clinical practice is desirable. * Demonstrated ability to work in unison with other professionals and non-professionals in a respectful and harmonious manner. Responsibilities: * Provide Physician oversight for activities related to the company's Behavioral Health Utilization Management, Care and Disease Management and Quality Management programs ensuring compliance with NCQA, Medicare, Medicaid, and other regulatory entities. Play an active role in preparing for related audits and information requests from such entities. * Establish the highest standards of best behavioral health practices for care provided to members through participation in the development of clinical practice guidelines and selection and procurement of suitable proprietary criteria and clinical pathways. * Provide physician education regarding The Health Plan BH utilization management and quality management protocols and initiatives. Work with individual physicians or physician groups to achieve acceptance and understanding of The Health Plan medical/BH appropriateness criteria, practice guidelines and patient care programs. * Carry out specific functions as outlined in the BH Utilization Management Program including: * a. Play a leadership role in the development and implementation of the BH Utilization Management Program including assisting in the development of the annual work plans and program evaluation. Serve as chairperson and or member of various utilization management committees as set forth in the Utilization Management Program Description. * b. Review clinical BH utilization and the delivery of care to members on a daily basis. Maintain daily interaction with hospital review, case managers, care managers, disease managers, pharmacy managers, claims managers and other staff. * c. Review all cases where medical/BH appropriateness is questioned and provide overall responsibility for authorization or non-authorization based on appropriateness of the health care services requested. * d. Available to communicate telephonically with practitioners in case review matters. * e. Available as needed to provide twenty-four hour coverage for case review matters. * f. Actively participates in the functioning of the plan appeal and grievance procedures. * Carry out specific functions as outlined in the Quality Management Program including: * a. Play leadership role in the development and implementation of the Quality Management Program including assisting in the development of the annual work plan and program evaluation. Serve as chairperson and/or member of various quality management committees as set forth in the Quality Management Program Description including but not limited to the Quality Improvement Committee, the Credentials Committee, the Pharmacy and Therapeutics Committee, the Transplant and Technology Committee, Utilization Management Committee and other related committees. * b. Monitors, evaluates, and validates clinical quality issues and refers them to the appropriate internal staff, committees or institutional regulatory bodies. * c. Collaborates in organizing a continuous quality improvement mechanism for The Health Plan and in identifying specific clinical goals and objectives for focus or priority. * d. Acts as a guide and resource to the Quality Management Program in the collection and analysis of data related to quality studies and surveys. Participates in the qualitative analysis of data to identify barriers and corrective actions as well as re-evaluation after intervention. * Works directly with Network Development staff to develop and coordinate effective provider education/intervention programs including providing input into provider training and education programs, review of provider manuals and direct contact with providers as needed. * Perform other duties and special projects as assigned to accomplish the goals of the organization. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment. 8:00am - 5:00pm 40

Maintain participating provider data in the credentialing/provider data mangement system and the claims operating system, including adding new providers, updating existing providers and terminating providers. Set up and maintain contracted rates to ensure provider contract compliance. Required: Associates degree or high school diploma/equivalent and/or two years experience working in health care operations, or equivalent experience with credentialing, claims, and provider data management. Excellent communication and writing skills. Experience in Microsoft Office (Excel, Word, Teams) and Adobe Acrobat with the ability to learn applications that support credentialing and provider data management processes. General understanding of managed care plans and health insurance. Critical thinking abilities along with the ability to work independently. Proven time management and organizational skills. Desired: College degree preferred. Experience with credentialing and provider data management system. Responsibilities: Maintain participating provider records in symplr Payer and the claims operating system with demographic, Tax ID, or other changes to ensure data accuracy. Ensure newly contracted providers are accurately entered into symplr Payer. Set up and maintain provider fee tables to ensure correct claims payment. Enter credentialing applications to initiate the credentialing cycle. Demonstrate compliance with NCQA NET 5, Element A-J and No Surprises Act to accurately populate provider directory information within the timely requirements. Demonstrate compliance with NCQA NET 4, Elements A & B and state regulations to notify members of a provider termination within the timely requirements. Manage returned mail, such as checks and EOPs, by researching and facilitating issue resolution, Adhere to all The Health Plan (THP) policies and procedures, as well as, following regulations and standards established by NCQA, CMS, BMS, and the states where THP serves its members. Research and resolve internal and external inquiries regarding provider status and system setup to ensure quality control. Work collaboratively with the Provider Delivery Services team as well as all internal departments. Assist with NCQA, CMS, BMS, state and internal audits. Assist with training and development of employees related to provider data quality processes. Maintain non-participating provider and dental records in the claims processing system with demographic, Tax ID, or other changes to ensure accuracy of information. Create new non-participating provider and dental records in the claims processing system based on the information received on a claim. Resolve data entry claims queue issues including data entry of non-participating providers. Basic pay class assignment and maintenance to ensure the accuracy of claims payment. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.

Under the general direction of the Pharmacy Operations Manager, the Member Advocate is responsible for coordinating copay assistance for members and directing members on how to apply for low-income subsidy for Medicare Part D. Required: High School diploma or equivalent. National Pharmacy Technician Certification One year experience in a retail, hospital, managed care, or other similar pharmacy setting. Minimum typing speed of 35 words per minute Demonstrate working knowledge of direct claims processing, pharmacy computer systems, spreadsheet applications (i.e., Microsoft Excel), phone system and other office/computer equipment as required. Knowledge of pharmaceutical generic and trade names. Ability to comprehend and follow established office routines, policies, and procedures. Effective oral and written communication skills, including grammar and spelling. Strong organizational skills, time management and multi-tasking abilities. Detail oriented with advanced analytical and problem-solving skills. Ability to work effectively as part of a team and independently. Provide excellent customer service. Follow all plan policies and procedures. Desired: Degree in health-related field. Experience performing medication authorizations in pharmacy or managed care environment. Responsibilities: Complete timely and accurate documentation of contacts and outcomes in referral platform. Performs research to identify appropriate community resources and maintains information of available resources to meet various member needs. Directs members on how to apply for low-income subsidy for Medicare Part D. Prioritizes assignments appropriately and maintains flexibility as new priorities arise. Promotes communications, both internally and externally, to enhance effectiveness or pharmacy services for membership. Strives to improve quality in all areas of responsibility and cooperate with all departments to improve quality throughout The Health Plan. Ensures that all financial assistance applications are processed timely and accurately. Provide excellent customer service to members and providers. Consults with clinical pharmacists for guidance and assist if necessary. Gathers clinical documentation necessary for the performance of medication reconciliation and yearly medication reviews and refers documentation to a Care Management Pharmacist for review if needed. Work DSNP IR referrals for diabetic and nebulizer testing supplies. Work any pharmacy mail marked “Return To Sender.” Back-up for ACD lines and completes medication coverage requests during peak seasons and if short staffed. Meets internal key performance indicators as defined in The Health Plan's Policies and Procedures. Member Advocates/Pharmacy Technicians are responsible for reporting any changes in licensure status (e.g., application declined/denied; license revoked/suspended or lapsed; notification of an investigation by licensing board; becoming subject to disciplinary action by a licensing board) to their direct supervisor throughout their term of employment. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.

Under the direction of the Manager, Provider Experience, the Practice Management Consultant provides education, training, and guidance for providers; drives quality discussions to increase member care, member satisfaction and provider satisfaction, responsible for performing on-site reviews of new and re-credentialed providers within their assigned territory; identify and educate providers requiring additional education (performed on-site, via conference call and/or via webinar) Required: College degree or 3-4 years' experience in a physician's office, payer agency, community agency or other health care environment Valid driver's license Previous customer service experience with exposure to claims and benefits interpretation and provider networking Knowledge of medical coding Knowledge of HEDIS and Star Ratings Computer experience with Microsoft Word, Excel, Power Point and Outlook Desired: Strong verbal and written communication skills with the ability to communicate (oral and written) effectively. Strong project management skills. Must be able to perform presentations for small and large audiences in person and remotely. Organizational skills with the ability to handle multiple tasks and/or projects at one time. Customer service skills with the ability to interact professionally and effectively with providers, and staff. Time management skills with the ability to prioritize and schedule daily activities for the most efficient use of time. Problem resolution skills. Ability to work under little supervision and act as a team member. Familiar with current managed care, State and/or Federal healthcare programs (Medicare, Medicaid) and the insurance industry. Experience in managed care, State and/or Federal health programs. Certified Medical Insurance Specialist (CMIS) and Certified Medical Coder (CMC). Value based reimbursement/initiatives/projects experience. Responsibilities: Held accountable for servicing providers within their territory and outside of territory, as assigned. Evaluate and monitor providers' performance standards and financial performance of contracts as requested to support THP goals. Make regular visits, in-person, by phone and/or video call, to providers and act as primary resource for driving quality, operational efficiency and membership growth and retention. Travel throughout THP managed care service area, as required or assigned. Ability to cover a large geographic area. Outreach to contracted provider offices to educate as necessary. Knowledge of standard credentialing procedures. Communicate changes and updates to providers. Assist other departments with outreach to contracted provider offices as needed. Identify workflow processes and training to develop target initiatives to improve quality reporting. Facilitate contracted provider meetings. Familiar with all product lines, including education on billing services necessary to enhance company initiatives. Assist management in provider and quality reporting requirements. Regularly attend conferences and webinars to expand knowledge base. Train and offer technical assistance to providers for all THP applications. Work directly with clinical data and analytics team to track service trends and educate providers. Implement and coordinate programs to build and nurture relationships between THP, providers and office managers. Coordinate with Quality Improvement team to complete quality and department initiatives. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.

Under the direct supervision of the Manager/Supervisor of Data Entry / Scanning, the Data Entry / Scanner Operator is responsible for the scanning of all claims & correspondence and the data entry of all these documents that have been scanned in by the Kodak scanner. Data Entry / Scanner Operator will be required to perform other duties and activities within the department as needed when requested by the Manager/Supervisor of Data Entry / Scanning. Required: High School graduate or equivalent; Self-starter, detail oriented, ability to prioritize and meet deadlines; Maintain confidentiality; Good communication skills; Must have at least beginner's typing abilities; Easily adapts to changes in work requirements. Desired: College degree and/or knowledge of ICD-9/ICD-10 & CPT codes not required but would be beneficial; Background in medical field helpful. Responsibilities: Demonstrates a complete understanding of departmental policies and procedures; Has established adequate proficiency in using the application necessary to perform most of the keying functions of Data Entry with a 90% competency in random monitoring audits; Builds up to a minimum of 100,000 KE-5 & KF15 keys per month and 1,000 OC Repair keys per month or scans up to 80,000 pages per month; Able to perform assigned tasks with minimal supervision; Maintains an annual performance evaluation of meets requirements; Consistently displays a positive attitude and acceptable attendance. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.

The Case Management/Disease Management Nurse Navigator is responsible for assessing moderate to high risk patients for case management/disease management intervention and coordinating the delivery of cost-effective, quality-based health care services for health plan members by development and implementation of care plans that address individual needs of the member, their benefit plan, and community resources. Directs intervention with moderate to high risk members, and provides education, support and oversight to other team members managing low risk members. Interfaces with providers of medical/behavioral services and equipment to facilitate effective communication, referrals, development of discharge planning and care plan development. Initiates contact with patient/family, physician, and health care providers/suppliers to discuss the care plan. Monitors, evaluates, extends, revises or closes treatment plans as appropriate. Evaluates cases for quality of care. Communicates case management plans and decisions. Understands and follows policies and procedures and performs care coordination duties and documentation in a timely manner. Handles moderate to high risk and/or complex cases. Initiates and leads the multi-disciplinary care planning process. Required: Registered Nurse with at least five (5) years' experience. Three (3) of those years may be work experience as a nurse's aide, LPN or other appropriate position in a clinical setting. (RN outside minimum experience may be waived for internal applicants currently employed as an LPN with written recommendation of current supervisor or manager). Preferred critical care or other acute care experience. Active Ohio or WV licensure upon hire. Ohio or West Virginia multistate licensure must be obtained within the 90-day probationary period and maintained throughout employment including compliance with State Boards of Nursing and continuing education policy. Other licensure as company expansion warrants. Demonstration of excellent oral, written, telephonic and interpersonal skills. Demonstration of proficient keyboarding skills and computer literacy with the ability to navigate through multiple systems. Flexibility and demonstration of the ability to balance an independent and team working environment, multitask, work in a fast-paced environment, and adapt to changing processes. Possession of a superior work ethic and a commitment to excellence and accountability. Proven ability to exercise independent and sound judgment in decision making, utilizing all relevant information with proactive identification and resolution of issues. Desired: Utilization Management, Quality Improvement, Case Management, Disease Management, or other Managed Care experience is desirable. Certification in an area of clinical expertise related to current work i.e., CDE, CCM, CMCN, Motivational Interviewing/MI Trainer, etc. Responsibilities: Coordinate and provide case management services that are safe, timely, effective, efficient, equitable, and client-centered. Handle case assignments, perform comprehensive and thorough medical, behavioral, functional and social determinant of health assessments, develop and maintain care plans, review case progress and determine case closure. Help members achieve wellness and autonomy. Facilitate multiple care aspects (care coordination, condition education, utilization management, information sharing, redirection/transitional care, cost containment, benefit maximization, etc) across the care continuum inclusive of communications with all relevant multi disciplinary care team members. Help members make informed decisions by acting as a resource and advocate regarding their clinical status and treatment options. Develop effective working relations within the industry and cooperate with medical/behavioral team members throughout the entire care coordination process. Arrange non-benefit services with community based agencies, external social services, health and governmental agencies. Thoroughly develop and document interactions with patients and families to keep track of their progress towards goals and to ensure satisfaction. Record case information, complete accurately and timely all necessary referrals, reviews, assessments, care plans, notes, actives, forms and workflows to produce results evidencing adherence to case management interrater review benchmarks and NCQA, CMS and/or BMS regulatory standards as appropriate. Promote quality and cost-effective interventions and outcomes in accordance with plan benefits. Assess and address motivational and psychosocial issues. Adhere to professional standards as outlined by protocols, rules and regulations.

The ESS is responsible for managing document queues to complete member reimbursement requests, provider pricing verification requests, network pricing appeals, and member balance bills. The ESS will also prepare pricing appeal response letters and other written correspondence sent via email or postal service including certified mail when needed. The ESS is responsible for timely completion of requests from the operations team. Required: High School graduate or equivalent. Detail oriented and good critical thinking skills. Superb organizational skills. Able to communicate clearly and accurately with members, coworkers and management. Ability to prioritize and meet deadlines. Work efficiently in a fast-paced environment. Proficient in computer skills including Microsoft Office programs (Word, Excel, Office). Desired: Previous administrative experience. Knowledge in medical terminology and CPT and ICD-9/ICD-10 coding. Knowledge in health insurance. Responsibilities: Answers all calls and correspondence in a timely, professional and friendly manner. Documents and tracks all information clearly and accurately. Completes work within deadlines. Communicates with members and providers as necessary to obtain information. Manages multiple tasks and priorities. Understands members benefits and plan to relay the information clearly and accurately. Understands claim detail, identifies claim issues and reports issues to management when necessary. Keep all member protected health information (PHI) confidential. Supports Manager and Employer Service Reps when needed. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.

Job Description The Transitional Care Social Worker is responsible for the navigation and advocacy of identified members stratified relevant to care transitions. These members require coordinated transitional care and integration into multiple health and social systems. This may include providing the member with information and assistance to access a wide spectrum of services directed at social, medical/behavioral and lifestyle interventions to promote health and wellness and support individualized goal attainment through care planning and self- management to prevent readmissions, demonstrate continuity of care, assist with discharge planning and SDOH needs for members at high risk for readmssion, members who have exhausted benefits, redirection of members who are utilizing out of network providers, facilitiating access to care for members who were seeing a provider who has termed with THP, transitioning care onto or off of THP to ensure continuity and providing support and directioin to members with high cost or complex care needs. Required: Social Work or related undergraduate degree with active and unrestricted license in good standing as a social worker in Ohio or West Virginia upon hire. All licensed staff are expected to hold active licenses in both Ohio and West Virginia by the end of their 90 day probationary period with demonstrated compliance with licensure and Board of Social Workers continuing education policy throughout hire. Relevant experience in a hospital, skilled nursing facility, outpatient unit or related setting. Excellent oral, written, telephonic and interpersonal skills to balance independent and team work environments. Demonstrated knowledge of Microsoft Office programs. Flexibility, ability to multi-task and work in a fast-paced environment and adapt to changing processes. Proficient keyboarding skills and computer literacy with the ability to navigate through multiple systems. Desired: In-depth knowledge and skills related to care resources, community resources, discharge planning and health care financial environments. Remains current through conferences, workshops and professional networking. Superior work ethic and commitment to excellence and accountability. Ability to demonstrate independent and sound judgment in decision making, utilizes all relevant information to proactively identify and resolve issues. Masters of Social Work desired but not required. Case Management Certification (CCM) or Certified Advanced Social Work Case Manager desired but not required. Responsibilities: Engages telephonically with members identified as high risk for hospital readmissions or transitional care need through direct communication with hospital social workers and discharge planners, network practitioners, other transitional care staff, case managers, and The Health Plan members or supportive others. Assists The Health Plan members identified with any transition of care need and/or their supportive others, The Health Plan staff, or practitioners in making community resource referrals. Also provides appropriate follow-up regarding the outcome of a referral. Performs research to identify appropriate community resources and maintains information of available resources to meet various member needs. Completes accurate and timely documentation of contacts, needs assessments, interventions and outcomes in The Health Plan's EMR platform. Collaborates with Health Plan staff in providing practitioner and facility education regarding available support services to assist members with transitional care needs. Works with The Health Plan staff to develop and implement programming for social intervention consistent with identified needs of specific member populations i.e. Medicare and Medicaid. Maintains a level of competency to deal with current SDOH trends, exhaustion of benefits by line of business, transition on or off THP insurance to ensure continuity of care. Strives to improve quality in all areas of responsibility and cooperate with all departments to improve quality throughout The Health Plan. Serves as assigned on departmental or company committees. Promotes communication, both internally and externally, to enhance effectiveness of transitional care services. Identifies opportunities for improvement in systems, processes, functions, programs, procedures and makes recommendations to management. Prioritizes assignments appropriately and maintains flexibility as new priorities arise. Participates in Transitional Care and Post Discharge Outreach. Social Workers are responsible for reporting any changes in licensure (e.g., application declined/denied; license revoked/suspended or lapsed; notification of an investigation by licensing board; becoming subject to disciplinary action by a licensing board) to their direct supervisor through their term of employment. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment. 8:00 AM to 5:00 PM 40

is NOT remote. As a Senior Software Engineer, you will play a key leadership role in architecting, building, and optimizing secure, scalable integration solutions across diverse systems. You will serve as both a technical expert and mentor, guiding a team of engineers and developers to deliver modern, robust software and data workflows. This role is ideal for an engineer who thrives in architect-level problem solving, enjoys technical leadership, and is passionate about continuous learning and mentoring others. Required: Master's degree in Computer Science, Engineering, or a related field. Expertise in software and solution architecture, with a focus on service-based and distributed systems. Advanced proficiency in .NET Core, REST APIs, workflow automation, and related modern technologies. Strong experience with SQL databases (design, performance, data integration) and ORM frameworks (e.g., Entity Framework). Hands-on experience with CI/CD pipelines, automated deployment, and version control (Azure DevOps, GitHub Actions, Jenkins, etc.). Deep understanding of data integration patterns, file standards, and translation tools (including EDI, when applicable). Up-to-date with current technology trends, best practices, and a demonstrated commitment to continuous professional growth. Extensive experience developing intuitive user interfaces and optimizing user workflows, with a strong focus on usability and front-end best practices. Demonstrated experience leading software development projects, setting technical direction, and establishing architectural standards. Proven ability to mentor and develop team members, fostering technical growth and a collaborative engineering culture. Strong communication, interpersonal, and cross-functional collaboration skills. Desired: Proven ability to mentor and develop team members, fostering technical growth and a collaborative engineering culture. Strong communication, interpersonal, and cross-functional collaboration skills. Responsibilities: Lead the design and implementation of secure, scalable, and maintainable system architectures. Set technical direction, promote best practices, and champion architectural standards across the engineering team. Mentor, coach, and provide guidance to analysts and developers; create opportunities for team learning and skill advancement. Foster a culture of collaboration, innovation, and knowledge sharing. Oversee all aspects of file and data workflows, ensuring data quality, compliance, and operational excellence. Collaborate with internal teams and external partners to ensure seamless system interoperability. Continuous Improvement: Evaluate, recommend, and adopt new technologies and frameworks to improve team productivity and system capability. Drive the implementation and optimization of CI/CD and workflow automation. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment. 8:00am - 5:00pm 40

Coordinates and integrates through review, all services that require pre-authorization including all new technology and experimental/investigational services using the clinical review algorithm and/or responsible to identify members that may require coordinated care management or disease management services, or transition of care services based on clinical risk scores, or information gathered from preauthorization review of submitted clinicals. Required: Registered Nurse with at least five (5) years' experience. Three (3) of those years may be work experience as a nurse's aide, LPN or other appropriate position in a clinical setting. (RN outside minimum experience may be waived for internal applicants currently employed as an LPN with written recommendation of current supervisor or manager). Preferred critical care or other acute care experience. Active Ohio or WV licensure upon hire. Ohio or West Virginia multistate licensure must be obtained within the 90-day probationary period and maintained throughout employment including compliance with State Boards of Nursing and continuing education policy. Other licensure as company expansion warrants. Demonstration of excellent oral, written, telephonic and interpersonal skills. Demonstration of proficient keyboarding skills and computer literacy with the ability to navigate through multiple systems. Flexibility and demonstration of the ability to balance an independent and team working environment, multitask, work in a fast-paced environment, and adapt to changing processes. Possession of a superior work ethic and a commitment to excellence and accountability. Proven ability to exercise independent and sound judgment in decision making, utilizing all relevant information with proactive identification and resolution of issues. Desired: Utilization Management, Quality Improvement, Case Management, Disease Management, or other Managed Care experience is desirable. Certification in an area of clinical expertise related to current work i.e., CDE, CCM, CMCN, Motivational Interviewing/MI Trainer, etc. Responsibilities: Enters data timely into preauthorization system and updates diagnoses, procedures, medical histories, and consults. Determines appropriateness of pre-authorizations using established clinical/behavioral health criteria and/or guidelines as appropriate per line of business. Reviews and evaluates relevant information including member history, medical records, group contracts, benefit design, plan limitations, exclusions, coordination of benefits and member eligibility in making decisions and recommendations that are consistent with sound medical and managed care practice. Appropriately forwards service requests that do not meet guidelines per clinical algorithm to the medical director. Submits requests for Single Case Agreements and/or Letters of Agreement per process according to line of business. Coordinates care in collaboration with the member, family, health care team members, providers, and other resources to intervene proactively to identify needed medical and/or behavioral health services. Identifies members that may need chronic disease navigation, complex case navigation, behavioral health, social service intervention and refers appropriately. Acts as a liaison between member, provider, and The Health Plan. Collaborates and shares knowledge and expertise with peers, supervisors, and other staff. Serves as assigned or as volunteers on departmental or company committees and attends departmental or work-group meetings as scheduled. Promotes communication, both internally and externally, to enhance effectiveness of medical management services. Identifies opportunities for improvement in systems, processes, functions, programs, procedures and makes recommendations to the appropriate management staff. Prioritizes assignments/referrals appropriately and maintains flexibility as new priorities arise. Identifies potential quality issues, variances, hospital acquired conditions and never events and refers to QI Department. Identifies requests for new technology and communicates that data to the medical policy director. Takes after-hours and weekend call on rotation as assigned (volunteer only). Strives to improve quality in all areas of responsibility and cooperates with all departments to improve quality through The Health Plan. Facilitates access to care, provides liaison services, advocates for, and educates members as needed. Educates providers when indicated. Identifies and reports potential high-cost cases to the reinsurance or stop loss carrier as appropriate per line of business. Demonstrate a working knowledge and adherence to contractual guidelines and policies of The Health Plan. Achieve optimal clinical and quality outcomes by effectively managing care and resources. Participate in quality improvement activities to achieve program outcomes. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.

The D-SNP (Dual-Eligible Special Needs Plan) Nurse Navigator is responsible for the navigation and advocacy of members who are dually eligible for both Medicare and Medicaid. These members often have multiple or complex medical and/or behavioral health, socioeconomic, and functional needs that require comprehensive care coordination services. These services may include navigation beyond the specific case or situation, providing the member with a wide spectrum of services directed at not only medical or behavioral changes but healthy lifestyles and optimal outcomes assuring quality and continuity of care within the managed care system. Care coordination directs intervention by offering education and support, liaising with providers of medical/behavioral services and equipment to facilitate effective communication, streamline referrals, assist in developing and implementing comprehensive individualized care plans, and supporting smooth discharge planning. This is achieved through the establishment of routine follow up to monitor, evaluate, revise or close care plan interventions and goals which support ongoing communication and interaction among the interdisciplinary care team and provides opportunities to appraise cases for quality of care. Required: Registered Nurse with at least five (5) years' experience. Three (3) of those years may be work experience as a nurse's aide, LPN or other appropriate position in a clinical setting. (RN outside minimum experience may be waived for internal applicants currently employed as an LPN with written recommendation of current supervisor or manager). Active Ohio or WV licensure upon hire. Ohio or West Virginia multistate licensure must be obtained within the 90-day probationary period and maintained throughout employment including compliance with State Boards of Nursing and continuing education policy. Other licensure as company expansion warrants. Demonstration of excellent oral, written, telephonic and interpersonal skills. Demonstration of proficient keyboarding skills and computer literacy with the ability to navigate through multiple systems. Flexibility and demonstration of the ability to balance an independent and team working environment, multitask, work in a fast-paced environment, and adapt to changing processes. Possession of a superior work ethic and a commitment to excellence and accountability. Proven ability to exercise independent and sound judgment in decision making, utilizing all relevant information with proactive identification and resolution of issues. Desired: Utilization Management, Quality Improvement, Case Management, Disease Management, or other Managed Care experience is desirable. Certification in an area of clinical expertise related to current work i.e., CDE, CCM, CMCN, Motivational Interviewing/MI Trainer, etc. Responsibilities: Coordinate and provide case management services that are safe, timely, effective, efficient, equitable, and client-centered. Handle case assignments, perform comprehensive and thorough medical, behavioral, functional and social determinant of health assessments, develop and maintain care plans, review case progress and determine case closure. Help members achieve wellness and autonomy. Facilitate multiple care aspects (care coordination, condition education, utilization management, information sharing, redirection/transitional care, cost containment, benefit maximization, etc) across the care continuum inclusive of communications with all relevant multi disciplinary care team members. Help members make informed decisions by acting as a resource and advocate regarding their clinical status and treatment options. Develop effective working relations within the industry and cooperate with medical/behavioral team members throughout the entire care coordination process. Arrange non-benefit services with community based agencies, external social services, health and governmental agencies. Thoroughly develop and document interactions with patients and families to keep track of their progress towards goals and to ensure satisfaction. Record case information, complete accurately and timely all necessary referrals, reviews, assessments, careplans, notes, activies, forms and workflows to produce results evidencing adherence to case management interrater review benchmarks and NCQA, CMS and/or BMS regualatory standards as appropriate. Promote quality and cost-effective interventions and outcomes in accordance with plan benefits. Assess and address motivational and psychosocial issues. Adhere to professional standards as outlined by protocols, rules and regulations. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment. 8:00am - 5:00pm 40

Job Description The Behavioral Health Medical Director position at The Health Plan (THP) involves providing clinical guidance to the Behavioral Health Care Coordination and Utilization Management teams. Key responsibilities include facilitating integrated BH rounds, making clinical coverage determinations, maintaining clinical integrity, and ensuring compliance with evidence-based guidelines. The role requires collaboration with various clinical professionals and leadership teams, focusing on recovery-oriented and cost-effective care.This will be a Dyad relationship with the Directors and VP's of the Clinical Services Department. Required: MD/DO with board certification in Psychiatry, with qualifications in Addiction Psychiatry or Medicine. A West Virginia and Ohio Physician License is required. Or willingness to obtain them witin 90 days. A minimum of three years of clinical experience beyond residency/fellowship is necessary, with supervisory and teaching experience preferred. ASAM Certification is required. Desired: Basic computer literacy. Prior leadership roles while in clinical practice is desirable. Demonstrated ability to work in unison with other professionals and non-professionals in a respectful and harmonious manner. Responsibilities: Provide Physician oversight for activities related to the company's Behavioral Health Utilization Management, Care and Disease Management and Quality Management programs ensuring compliance with NCQA, Medicare, Medicaid, and other regulatory entities. Play an active role in preparing for related audits and information requests from such entities. Establish the highest standards of best behavioral health practices for care provided to members through participation in the development of clinical practice guidelines and selection and procurement of suitable proprietary criteria and clinical pathways. Provide physician education regarding The Health Plan BH utilization management and quality management protocols and initiatives. Work with individual physicians or physician groups to achieve acceptance and understanding of The Health Plan medical/BH appropriateness criteria, practice guidelines and patient care programs. Carry out specific functions as outlined in the BH Utilization Management Program including: a. Play a leadership role in the development and implementation of the BH Utilization Management Program including assisting in the development of the annual work plans and program evaluation. Serve as chairperson and or member of various utilization management committees as set forth in the Utilization Management Program Description. b. Review clinical BH utilization and the delivery of care to members on a daily basis. Maintain daily interaction with hospital review, case managers, care managers, disease managers, pharmacy managers, claims managers and other staff. c. Review all cases where medical/BH appropriateness is questioned and provide overall responsibility for authorization or non-authorization based on appropriateness of the health care services requested. d. Available to communicate telephonically with practitioners in case review matters. e. Available as needed to provide twenty-four hour coverage for case review matters. f. Actively participates in the functioning of the plan appeal and grievance procedures. Carry out specific functions as outlined in the Quality Management Program including: a. Play leadership role in the development and implementation of the Quality Management Program including assisting in the development of the annual work plan and program evaluation. Serve as chairperson and/or member of various quality management committees as set forth in the Quality Management Program Description including but not limited to the Quality Improvement Committee, the Credentials Committee, the Pharmacy and Therapeutics Committee, the Transplant and Technology Committee, Utilization Management Committee and other related committees. b. Monitors, evaluates, and validates clinical quality issues and refers them to the appropriate internal staff, committees or institutional regulatory bodies. c. Collaborates in organizing a continuous quality improvement mechanism for The Health Plan and in identifying specific clinical goals and objectives for focus or priority. d. Acts as a guide and resource to the Quality Management Program in the collection and analysis of data related to quality studies and surveys. Participates in the qualitative analysis of data to identify barriers and corrective actions as well as re-evaluation after intervention. Works directly with Network Development staff to develop and coordinate effective provider education/intervention programs including providing input into provider training and education programs, review of provider manuals and direct contact with providers as needed. Perform other duties and special projects as assigned to accomplish the goals of the organization. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment. 8:00am - 5:00pm 40

Maintain participating provider data in the credentialing/provider data mangement system and the claims operating system, including adding new providers, updating existing providers and terminating providers. Set up and maintain contracted rates to ensure provider contract compliance. Required: Associates degree or high school diploma/equivalent and/or two years experience working in health care operations, or equivalent experience with credentialing, claims, and provider data management. Excellent communication and writing skills. Experience in Microsoft Office (Excel, Word, Teams) and Adobe Acrobat with the ability to learn applications that support credentialing and provider data management processes. General understanding of managed care plans and health insurance. Critical thinking abilities along with the ability to work independently. Proven time management and organizational skills. Desired: College degree preferred. Experience with credentialing and provider data management system. Responsibilities: Maintain participating provider records in symplr Payer and the claims operating system with demographic, Tax ID, or other changes to ensure data accuracy. Ensure newly contracted providers are accurately entered into symplr Payer. Set up and maintain provider fee tables to ensure correct claims payment. Enter credentialing applications to initiate the credentialing cycle. Demonstrate compliance with NCQA NET 5, Element A-J and No Surprises Act to accurately populate provider directory information within the timely requirements. Demonstrate compliance with NCQA NET 4, Elements A & B and state regulations to notify members of a provider termination within the timely requirements. Manage returned mail, such as checks and EOPs, by researching and facilitating issue resolution, Adhere to all The Health Plan (THP) policies and procedures, as well as, following regulations and standards established by NCQA, CMS, BMS, and the states where THP serves its members. Research and resolve internal and external inquiries regarding provider status and system setup to ensure quality control. Work collaboratively with the Provider Delivery Services team as well as all internal departments. Assist with NCQA, CMS, BMS, state and internal audits. Assist with training and development of employees related to provider data quality processes. Maintain non-participating provider and dental records in the claims processing system with demographic, Tax ID, or other changes to ensure accuracy of information. Create new non-participating provider and dental records in the claims processing system based on the information received on a claim. Resolve data entry claims queue issues including data entry of non-participating providers. Basic pay class assignment and maintenance to ensure the accuracy of claims payment. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment. 8:00am -5:00pm 40 hours

Under the direct supervision of the Manager of Credentialing, responsible for credentialing of providers and associated activities in support of the credentialing process in accordance with established Health Plan credentialing policies following NCQA, Medicare, the state of West Virginia, West Virginia Medicaid, and the state of Ohio policies and procedures. Required: * High school diploma or equivalent. * At least two years related healthcare experience. * Strong organizational, interpersonal, and critical thinking skills. * Excellent communication skills, both written and verbal * Ability to multi-task, prioritize workload to meet deadlines, and pay meticulous attention to detail. * Ability to troubleshoot, problem solve and work as a team as well as independently. * Experience in Microsoft Office Programs such as Word, Excel and Adobe Acrobat. Desired: * College Degree. * Previous credentialing experience. * CPCS Certification. * Experience with data systems. * Knowledge of medical coding and terminology. Responsibilities: * Performs provider credentialing and recredentialing functions. * Daily monitoring of application status and documents progress on tracking log. * Review and process providers initial credentialing and recredentialing applications and supporting documentation to identify possible issues. Follows up with responsible party to obtain missing information. * Ensure that recredentialing applications are completed timely to prevent any lapse in participation. * Identifies credentialing applications with variances and compiles information for credential committee review. * Accurate data entry, document scanning, and navigation of provider data systems. * Adheres to all policies and procedures of The Health Plan and other regulatory/governing entities as well as following standards established by NCQA, CMS, BMS, and the states of West Virginia and Ohio. * Assists with national, state, and internal audits. * Works collaboratively with the Provider Delivery Services team as well as all internal departments. * Teamwork to manage credentialing application volume. * Assists with training and development of employees related to the credentialing process. * Performs monthly reviews of applicable state licensing boards to identify adverse actions. * Performs monthly reviews of government exclusion databases. * Maintains confidentiality of provider information. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment. 8:00am - 5:00pm 40

The Transitional Care Social Worker is responsible for the navigation and advocacy of identified members stratified relevant to care transitions. These members require coordinated transitional care and integration into multiple health and social systems. This may include providing the member with information and assistance to access a wide spectrum of services directed at social, medical/behavioral and lifestyle interventions to promote health and wellness and support individualized goal attainment through care planning and self- management to prevent readmissions, demonstrate continuity of care, assist with discharge planning and SDOH needs for members at high risk for readmssion, members who have exhausted benefits, redirection of members who are utilizing out of network providers, facilitiating access to care for members who were seeing a provider who has termed with THP, transitioning care onto or off of THP to ensure continuity and providing support and directioin to members with high cost or complex care needs. Required: Social Work or related undergraduate degree with active and unrestricted license in good standing as a social worker in Ohio or West Virginia upon hire. All licensed staff are expected to hold active licenses in both Ohio and West Virginia by the end of their 90 day probationary period with demonstrated compliance with licensure and Board of Social Workers continuing education policy throughout hire. Relevant experience in a hospital, skilled nursing facility, outpatient unit or related setting. Excellent oral, written, telephonic and interpersonal skills to balance independent and team work environments. Demonstrated knowledge of Microsoft Office programs. Flexibility, ability to multi-task and work in a fast-paced environment and adapt to changing processes. Proficient keyboarding skills and computer literacy with the ability to navigate through multiple systems. Desired: In-depth knowledge and skills related to care resources, community resources, discharge planning and health care financial environments. Remains current through conferences, workshops and professional networking. Superior work ethic and commitment to excellence and accountability. Ability to demonstrate independent and sound judgment in decision making, utilizes all relevant information to proactively identify and resolve issues. Masters of Social Work desired but not required. Case Management Certification (CCM) or Certified Advanced Social Work Case Manager desired but not required. Responsibilities: Engages telephonically with members identified as high risk for hospital readmissions or transitional care need through direct communication with hospital social workers and discharge planners, network practitioners, other transitional care staff, case managers, and The Health Plan members or supportive others. Assists The Health Plan members identified with any transition of care need and/or their supportive others, The Health Plan staff, or practitioners in making community resource referrals. Also provides appropriate follow-up regarding the outcome of a referral. Performs research to identify appropriate community resources and maintains information of available resources to meet various member needs. Completes accurate and timely documentation of contacts, needs assessments, interventions and outcomes in The Health Plan's EMR platform. Collaborates with Health Plan staff in providing practitioner and facility education regarding available support services to assist members with transitional care needs. Works with The Health Plan staff to develop and implement programming for social intervention consistent with identified needs of specific member populations i.e. Medicare and Medicaid. Maintains a level of competency to deal with current SDOH trends, exhaustion of benefits by line of business, transition on or off THP insurance to ensure continuity of care. Strives to improve quality in all areas of responsibility and cooperate with all departments to improve quality throughout The Health Plan. Serves as assigned on departmental or company committees. Promotes communication, both internally and externally, to enhance effectiveness of transitional care services. Identifies opportunities for improvement in systems, processes, functions, programs, procedures and makes recommendations to management. Prioritizes assignments appropriately and maintains flexibility as new priorities arise. Participates in Transitional Care and Post Discharge Outreach. Social Workers are responsible for reporting any changes in licensure (e.g., application declined/denied; license revoked/suspended or lapsed; notification of an investigation by licensing board; becoming subject to disciplinary action by a licensing board) to their direct supervisor through their term of employment. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment. 8:00 AM to 5:00 PM 40

Job Description is NOT remote. As a Senior Software Engineer, you will play a key leadership role in architecting, building, and optimizing secure, scalable integration solutions across diverse systems. You will serve as both a technical expert and mentor, guiding a team of engineers and developers to deliver modern, robust software and data workflows. This role is ideal for an engineer who thrives in architect-level problem solving, enjoys technical leadership, and is passionate about continuous learning and mentoring others. Required: Master's degree in Computer Science, Engineering, or a related field. Expertise in software and solution architecture, with a focus on service-based and distributed systems. Advanced proficiency in .NET Core, REST APIs, workflow automation, and related modern technologies. Strong experience with SQL databases (design, performance, data integration) and ORM frameworks (e.g., Entity Framework). Hands-on experience with CI/CD pipelines, automated deployment, and version control (Azure DevOps, GitHub Actions, Jenkins, etc.). Deep understanding of data integration patterns, file standards, and translation tools (including EDI, when applicable). Up-to-date with current technology trends, best practices, and a demonstrated commitment to continuous professional growth. Extensive experience developing intuitive user interfaces and optimizing user workflows, with a strong focus on usability and front-end best practices. Demonstrated experience leading software development projects, setting technical direction, and establishing architectural standards. Proven ability to mentor and develop team members, fostering technical growth and a collaborative engineering culture. Strong communication, interpersonal, and cross-functional collaboration skills. Desired: Proven ability to mentor and develop team members, fostering technical growth and a collaborative engineering culture. Strong communication, interpersonal, and cross-functional collaboration skills. Responsibilities: Lead the design and implementation of secure, scalable, and maintainable system architectures. Set technical direction, promote best practices, and champion architectural standards across the engineering team. Mentor, coach, and provide guidance to analysts and developers; create opportunities for team learning and skill advancement. Foster a culture of collaboration, innovation, and knowledge sharing. Oversee all aspects of file and data workflows, ensuring data quality, compliance, and operational excellence. Collaborate with internal teams and external partners to ensure seamless system interoperability. Continuous Improvement: Evaluate, recommend, and adopt new technologies and frameworks to improve team productivity and system capability. Drive the implementation and optimization of CI/CD and workflow automation. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment. 8:00am - 5:00pm 40

Job Description The D-SNP (Dual-Eligible Special Needs Plan) Nurse Navigator is responsible for the navigation and advocacy of members who are dually eligible for both Medicare and Medicaid. These members often have multiple or complex medical and/or behavioral health, socioeconomic, and functional needs that require comprehensive care coordination services. These services may include navigation beyond the specific case or situation, providing the member with a wide spectrum of services directed at not only medical or behavioral changes but healthy lifestyles and optimal outcomes assuring quality and continuity of care within the managed care system. Care coordination directs intervention by offering education and support, liaising with providers of medical/behavioral services and equipment to facilitate effective communication, streamline referrals, assist in developing and implementing comprehensive individualized care plans, and supporting smooth discharge planning. This is achieved through the establishment of routine follow up to monitor, evaluate, revise or close care plan interventions and goals which support ongoing communication and interaction among the interdisciplinary care team and provides opportunities to appraise cases for quality of care. Required: Registered Nurse with at least five (5) years' experience. Three (3) of those years may be work experience as a nurse's aide, LPN or other appropriate position in a clinical setting. (RN outside minimum experience may be waived for internal applicants currently employed as an LPN with written recommendation of current supervisor or manager). Active Ohio or WV licensure upon hire. Ohio or West Virginia multistate licensure must be obtained within the 90-day probationary period and maintained throughout employment including compliance with State Boards of Nursing and continuing education policy. Other licensure as company expansion warrants. Demonstration of excellent oral, written, telephonic and interpersonal skills. Demonstration of proficient keyboarding skills and computer literacy with the ability to navigate through multiple systems. Flexibility and demonstration of the ability to balance an independent and team working environment, multitask, work in a fast-paced environment, and adapt to changing processes. Possession of a superior work ethic and a commitment to excellence and accountability. Proven ability to exercise independent and sound judgment in decision making, utilizing all relevant information with proactive identification and resolution of issues. Desired: Utilization Management, Quality Improvement, Case Management, Disease Management, or other Managed Care experience is desirable. Certification in an area of clinical expertise related to current work i.e., CDE, CCM, CMCN, Motivational Interviewing/MI Trainer, etc. Responsibilities: Coordinate and provide case management services that are safe, timely, effective, efficient, equitable, and client-centered. Handle case assignments, perform comprehensive and thorough medical, behavioral, functional and social determinant of health assessments, develop and maintain care plans, review case progress and determine case closure. Help members achieve wellness and autonomy. Facilitate multiple care aspects (care coordination, condition education, utilization management, information sharing, redirection/transitional care, cost containment, benefit maximization, etc) across the care continuum inclusive of communications with all relevant multi disciplinary care team members. Help members make informed decisions by acting as a resource and advocate regarding their clinical status and treatment options. Develop effective working relations within the industry and cooperate with medical/behavioral team members throughout the entire care coordination process. Arrange non-benefit services with community based agencies, external social services, health and governmental agencies. Thoroughly develop and document interactions with patients and families to keep track of their progress towards goals and to ensure satisfaction. Record case information, complete accurately and timely all necessary referrals, reviews, assessments, careplans, notes, activies, forms and workflows to produce results evidencing adherence to case management interrater review benchmarks and NCQA, CMS and/or BMS regualatory standards as appropriate. Promote quality and cost-effective interventions and outcomes in accordance with plan benefits. Assess and address motivational and psychosocial issues. Adhere to professional standards as outlined by protocols, rules and regulations. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment. 8:00am - 5:00pm 40

The Medicare Enrollment Representative is responsible for timely processing of enrollment and disenrollment requests using CMS guidelines and policies. They are also responsible for timely completion of all correspondence and reporting functions associated with the Medicare Enrollment Unit and have knowledge of how the Enrollment functions affect other Plan Units and Departments. The Medicare Enrollment Representative provides Sales Support as needed during peak sales periods. Required: High School Diploma. Typing and Computer Skills. Good telephone and communication skills. Self-starter, detail oriented, ability to prioritize and meet deadlines. Maintain confidentiality. Mathematical skills. Good work ethic (i.e. adequate learning skills, even temperament, following instructions, retains information., works well with others). Easily adapts to changes in work requirement. Desired: Familiar with Medicare Enrollment and Disenrollment processes. Medical terminology. Familiar with CMS Regulations and Guidelines. Knowledge of CPT, ICD-9 & ICD-10 coding. Responsibilities: Communicate with current and prospective members professionally, accurately and thoroughly. Answer prospective sales phone line and route calls to appropriate licensed Sales staff. Records all calls accurately in the Customer Service Module or Medicare Call Log. Complete a variety of enrollment and disenrollment functions. Knowledge of how the Enrollment area functions affect other units and departments. Assist with the completion of a variety of reports in accordance with CMS requirements and guidelines (i.e. TRR, BEQs and EDVs) Process correspondence. Report all suspicious issues to the Compliance Department or Departmental Manager. Keep all former, current or prospective members (and other Employee's) Protected Health Information (PHI) confidential. Must be willing to work Overtime if required to meet the CMS timeliness requirements. Participate in external and/or internal trainings as required. Consistently display a positive attitude and acceptable attendance. Assist with lobby traffic for current and prospective members with Enrollment/Disenrollment questions and concerns. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.

The Transitional Care Social Worker is responsible for the navigation and advocacy of identified members stratified relevant to care transitions. These members require coordinated transitional care and integration into multiple health and social systems. This may include providing the member with information and assistance to access a wide spectrum of services directed at social, medical/behavioral and lifestyle interventions to promote health and wellness and support individualized goal attainment through care planning and self- management to prevent readmissions, demonstrate continuity of care, assist with discharge planning and SDOH needs for members at high risk for readmssion, members who have exhausted benefits, redirection of members who are utilizing out of network providers, facilitiating access to care for members who were seeing a provider who has termed with THP, transitioning care onto or off of THP to ensure continuity and providing support and directioin to members with high cost or complex care needs. Required: * Social Work or related undergraduate degree with active and unrestricted license in good standing as a social worker in Ohio or West Virginia upon hire. All licensed staff are expected to hold active licenses in both Ohio and West Virginia by the end of their 90 day probationary period with demonstrated compliance with licensure and Board of Social Workers continuing education policy throughout hire. * Relevant experience in a hospital, skilled nursing facility, outpatient unit or related setting. * Excellent oral, written, telephonic and interpersonal skills to balance independent and team work environments. * Demonstrated knowledge of Microsoft Office programs. * Flexibility, ability to multi-task and work in a fast-paced environment and adapt to changing processes. * Proficient keyboarding skills and computer literacy with the ability to navigate through multiple systems. Desired: * In-depth knowledge and skills related to care resources, community resources, discharge planning and health care financial environments. Remains current through conferences, workshops and professional networking. * Superior work ethic and commitment to excellence and accountability. * Ability to demonstrate independent and sound judgment in decision making, utilizes all relevant information to proactively identify and resolve issues. * Masters of Social Work desired but not required. * Case Management Certification (CCM) or Certified Advanced Social Work Case Manager desired but not required. Responsibilities: * Engages telephonically with members identified as high risk for hospital readmissions or transitional care need through direct communication with hospital social workers and discharge planners, network practitioners, other transitional care staff, case managers, and The Health Plan members or supportive others. * Assists The Health Plan members identified with any transition of care need and/or their supportive others, The Health Plan staff, or practitioners in making community resource referrals. Also provides appropriate follow-up regarding the outcome of a referral. * Performs research to identify appropriate community resources and maintains information of available resources to meet various member needs. * Completes accurate and timely documentation of contacts, needs assessments, interventions and outcomes in The Health Plan's EMR platform. * Collaborates with Health Plan staff in providing practitioner and facility education regarding available support services to assist members with transitional care needs. * Works with The Health Plan staff to develop and implement programming for social intervention consistent with identified needs of specific member populations i.e. Medicare and Medicaid. * Maintains a level of competency to deal with current SDOH trends, exhaustion of benefits by line of business, transition on or off THP insurance to ensure continuity of care. * Strives to improve quality in all areas of responsibility and cooperate with all departments to improve quality throughout The Health Plan. * Serves as assigned on departmental or company committees. * Promotes communication, both internally and externally, to enhance effectiveness of transitional care services. * Identifies opportunities for improvement in systems, processes, functions, programs, procedures and makes recommendations to management. * Prioritizes assignments appropriately and maintains flexibility as new priorities arise. * Participates in Transitional Care and Post Discharge Outreach. * Social Workers are responsible for reporting any changes in licensure (e.g., application declined/denied; license revoked/suspended or lapsed; notification of an investigation by licensing board; becoming subject to disciplinary action by a licensing board) to their direct supervisor through their term of employment. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment. 8:00 AM to 5:00 PM 40