Job Objective / Purpose

To provide end-to-end medical, operational, and strategic oversight across claims adjudication, provider management, accreditation, and internal medical support—serving as a critical bridge between Clinical, Customer Service, Finance, and Provider Networks.

Responsibilities

• Lead provider engagement initiatives (planning, organizing, and execution)
• Approve/deny reconciliation of accounts impacting provider payments
• Perform in-patient adjudication, including proper segregation of illnesses
• Review and approve facility accreditation and any changes
• Handle and resolve Customer Service (CS) medical concerns and escalations
• Review and evaluate contracts (providers)
• Screen, accredit, and onboard CCM and clinic management doctors
• Monitor PROs’ KRAs and overall performance
• Initiate and support NetSuite PRT module upgrades (medical validation and process ...