Jobs at Neighborhood Health Plan of Rhode Island

Supports provider outreach, education, compliance tracking, and issue resolution for a managed care organization. Maintains provider data, training records, distribution lists, and Salesforce reports; responds to provider inquiries; educates providers on health plan policies; and collaborates across departments to improve provider satisfaction, compliance, and network operations.

Coordinates intake, assignment, tracking, correspondence, and resolution monitoring for Medicaid, Medicare, and Commercial grievances and appeals. Manages external appeals, maintains secure electronic records, monitors regulatory deadlines, coordinates with internal departments and delegated entities, reviews compliance forms with Legal, and supports team training. Requires strong organization, communication, analytical, customer service, healthcare systems, and regulatory knowledge.

Perform audits of auto-adjudicated and manually processed medical claims to ensure contractual and regulatory compliance; identify error trends and root causes; prepare audit reports and corrective actions; support UAT and system impact analyses; train and advise internal/external teams; report suspected fraud and assist with reprocessing guidance.

Design, develop, test, deploy, and support end-to-end automation solutions using UiPath and related tools. Integrate automations with databases and APIs, write and troubleshoot SQL, maintain production bots, perform root cause analysis, produce documentation, and collaborate with stakeholders to improve automation standards.

Lead and manage Configuration Services for claims systems: oversee requirements, deployments, vendor SLAs, defect management, SDLC/change control, team performance, process documentation, and reporting to senior leadership to ensure accuracy and operational improvements.

Design, implement, and maintain data governance frameworks and policies; monitor and improve data quality; classify and manage metadata; ensure privacy/HIPAA compliance; evaluate governance tools; report to stakeholders; drive process improvements and remediation.

Develops and manages provider fee schedules and alternative payment methodologies, builds financial models for reimbursement, audits and configures claim systems, performs complex analyses and reporting, coordinates with auditors/actuaries, and supports provider negotiations while ensuring regulatory and corporate compliance.