Teams at Elevance Health

Processes moderately complex prescriptions and prior authorization requests, verifies member, provider, and drug information, and troubleshoots adjudication issues. Assists with configuring and quality-checking prior authorization decision trees, implementing clinical programs, and ensuring Medicare and Medicaid compliance. Communicates determinations to relevant parties and educates providers about pharmacy rules, medication resources, and assistance programs.

Manages small to medium projects from initiation through closeout, including charters, schedules, budgets, communications, team coordination, issue resolution, scope changes, testing, quality reviews, approvals, and deployment planning. Partners with sponsors and business stakeholders to align projects with organizational goals, monitor ROI, and report progress. The role requires at least three years of project management experience, including two years leading project tasks, and is based in San Juan or Mayaguez, Puerto Rico with a hybrid schedule.

Conducts provider audits by reviewing medical records, bills, contracts, claims, and reimbursement policies. Selects claims and providers for review, identifies billing anomalies and potential abuse, validates overpayments, presents findings, and prepares audit reports. The role also mentors auditors, develops policies and educational materials, and represents the audit function on task forces and committees.