Teams at Neighborhood Health Plan of Rhode Island

Leads healthcare system configuration, business analysis, testing, implementation, documentation, auditing, and production turnover. Translates business requirements into technical specifications, configures benefit adjudication rules, resolves escalated issues, identifies automation opportunities, and supports process improvements. Serves as a subject matter expert and liaison between business and technical teams while coordinating projects, mentoring analysts, and maintaining configuration controls for HealthRules, Optum CES, Burgess Source, and related systems.

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.