BlueCross BlueShield of Tennessee

Manager

• Supporting utilization management functions for more complex and non-routine cases as needed.
• Serving as a liaison between members, providers and internal/external customers in coordination of health care delivery and benefits programs.
• Overseeing highly complex cases identified through various mechanisms to ensure effective implementation of interventions, and to ensure efficient utilization of benefits.
• Performing the essential activities of case management: assessment, planning, implementation, coordinating, monitoring, outcomes and evaluation.
• Perform case management activities in community settings including face to face with members as required.

BH Case Manager – Federal Employee Program

• Supporting utilization management functions for more complex and non-routine cases as needed.
• Serving as a liaison between members, providers and internal/external customers in coordination of health care delivery and benefits programs.
• Overseeing highly complex cases identified through various mechanisms to ensure effective implementation of interventions, and to ensure efficient utilization of benefits.
• Performing the essential activities of case management: assessment, planning, implementation, coordinating, monitoring, outcomes and evaluation.
• Digital positions must have the ability to effectively communicate via digital channels and offer technical support.

Case Manager

• Manage a mixed caseload consisting of both ongoing members and short-term cases focused on immediate care coordination needs
• Provide comprehensive care coordination and case management for dual-eligible members with complex behavioral health needs
• Collaborate within an integrated care team that aligns behavioral and physical health services
• Partner closely with members, caregivers, providers, and community resources to ensure seamless, coordinated care
• Support members in navigating Medicare and Medicaid benefits
• Advocate to improve health outcomes, access to care, and overall quality of life
• Oversee highly complex cases identified through various mechanisms to ensure effective implementation of interventions
• Perform case management activities in community settings including face to face with members as required

Behavioral Health Case Manager

Consultant

• Interfaces with provider quality programs, as well as with other cross-functional programs across the Enterprise functioning as consultant on provider quality performance and improvement initiatives.
• Works closely in collaboration with multi-disciplinary member and provider facing teams to execute provider pay for quality programs which align goals to achieve high quality care.
• Conducts frequent face-to-face or virtual provider office visits and functions as subject-matter consultant on provider performance quality measures, reporting, and data.
• Drives and directs recommendations for action designed to achieve quality and productivity improvement goals.
• Provides education to internal as well as external stakeholders on best practices in delivering high quality care and functions as a liaison regarding quality support tools provided to stakeholders; looking beyond the purely “medical” issues confronting families.
• Exhibit advanced and comprehensive knowledge of the PCMH Model of Care, as well as NCQA’s Recognition Program. This includes demonstrated expertise in the foundational concepts, detailed criteria, and procedural elements integral to the recognition process.

Provider Quality Consultant

• Support members within IDD population
• Collaborate part of a specialized team focused on ICF/IID support
• Manage a set caseload of long-term members
• Perform case management activities in community settings
• Oversee highly complex cases and ensure effective care coordination

BH Case Manager – ICF

Pharmacist

• Utilize clinical and analytical data to evaluate product performance and develop strategic pharmacy benefit options tailored to customer needs.
• Serve as the pharmacy subject matter expert throughout the development, implementation, and maintenance of drug solutions aligned with enterprise strategy.
• Prepare and present pharmacy-related information to employer groups, benefit representatives, brokers, and internal account teams to educate on industry trends and recommend solutions.
• Partner with enterprise leaders to identify opportunities that meet market needs and comply with state and federal regulatory requirements.
• Collaborate across product, clinical, and operational teams to ensure pharmacy strategies are integrated and responsive to evolving customer and market demands.
• Lead initiatives to evolve benefit strategies and pharmacy offerings in response to emerging trends and client needs.
• Leverage pharmacy acumen to articulate the clinical and economic value of pharmacy solutions in support of enterprise growth and retention strategies.

Corporate Pharmacy Director

Administration

• Maintain and monitor applications to ensure performance and availability
• Apply standard operational concepts, techniques, and procedures
• Resolve escalated issues pertaining to platform applications
• Execute update/enhancement releases
• Develop policies and procedures for infrastructure platforms

Platform Administrator

Compliance

• Coordinate highly sensitive reviews conducted by government agencies such as TDCI, CMS, OPM/FEP, DOL, etc.
• Assist on special assignments and workgroups concerning enterprise level compliance processes and enhancements
• Serve as a subject matter expert in regulatory research and interpretation, data analysis, audit principles, project management techniques, and general knowledge of industry best practices
• Manage scope and lead multiple projects including the execution of successful change management processes as requested by leadership
• Oversee project processes and procedures; monitor the productivity and performance of project team
• Track, report and resolve issues; evaluate project activities, build contingency plans and execute corrective action when necessary

Principal Ethics and Compliance Consultant

Platform Engineer

• Manage the onboarding and offboarding of network devices within monitoring platforms
• Develop and maintain dashboards, alerts, and performance metrics
• Partner with the Network Engineering team to optimize monitoring strategies and visibility
• Support and enhance enterprise monitoring solutions
• Certify multiple hardware platforms and the interrelationship/interoperability of different operating systems and complex environments
• Provide technical leadership and responsibility for the installation and certification of all supporting software and hardware
• Develop data architecture to support both the production system, and the backend data science and modeling tools
• Recommends/designs structures and tools for systems which meet business needs

Senior Platform Engineer

Data Engineer

• Build and optimize data pipelines that power critical system and vendor integrations
• Partner closely with data engineers, business analysts, vendors, and stakeholders
• Troubleshoot scalable data pipelines and support data warehouse structures
• Participate in an on-call rotation and collaborate across teams

Associate Data Engineer II

• support the development and maintenance of data pipelines
• partner closely with data engineers, business analysts, and stakeholders
• participate in an on-call rotation
• design, develop, modify, or integrate information systems

Associate Data Engineer

• Perform ongoing and ad-hoc research to help answer questions around business performance, data anomalies and future claim projections.
• Summarize findings for logical presentation and work with business contacts to develop effective product and process solutions.
• Developing and Maintaining the database of past claims to support the actuarial processes of determining premium rates for health insurance products.
• Analyze large amounts of complex data for drivers of business and/or industry trends.
• Ensure that any ad hoc data requests are done in an accurate and timely manner and presented in a clear, organized fashion.

Senior Data Consultant

AI Engineer

• Lead the ideation, development, and productionalization of sophisticated AI solutions tailored for healthcare payer use cases.
• Architect, design, and implement complex, state-of-the-art AI models and algorithms, leveraging Python and cloud platforms like GCP Vertex AI.
• Partner strategically with product teams and business stakeholders to define and prioritize opportunities for applying advanced AI techniques to solve critical business challenges and drive process automation.
• Conduct in-depth research and maintain expertise in the latest advancements in AI, championing the adoption of cutting-edge techniques and methodologies within the team.
• Architect and develop robust, scalable, and efficient systems and code bases for deploying AI models into production environments, ensuring high availability and performance.
• Serve as a key technical advisor to our internal Lines-of-Businesses, understanding complex needs, gathering requirements, and translating them into impactful, actionable AI solutions.
• Define and oversee the evaluation and validation frameworks for AI models, ensuring their accuracy, reliability, fairness, and performance exceed business requirements.
• Mentor and guide junior engineers on best practices in AI development, model implementation, and system design.

Senior AI Engineer

Full-stack Engineer

• Formulates and defines system scope and objectives through research and fact-finding to design, develop, modify, or integrate complex information systems.
• Devises or modifies application systems and procedures to optimize functional requirements including capacity, operating time, response time, and form of desired results.
• Designs, codes, tests, debugs, and documents programs, subroutines, and scripts.
• Develops and implements program/system test plans.
• Devises data verification methods and standard system procedures.
• Responds to system failures and performance events by taking appropriate measures to reduce system downtime and eliminate recurrence of problems.
• May conduct research on software and hardware products to justify recommendations and support management in budgeting and purchasing efforts.
• Acts as expert technical resource to development staff in all phases of the development and implementation process.

Senior Software Engineer

• Support critical BlueCard claims processing by maintaining and enhancing internal-facing applications.
• Help modernize legacy systems.
• Collaborate with a variety of technologies including C#, MQ Series, Java, WebSphere, Linux, Windows.
• Design, code, test, debug, and document programs, subroutines, and scripts.
• Serve in project team roles for small to medium efforts or manage phases of medium to large efforts.
• Maintain technical skill set for software languages, databases, platforms, operating systems, and networks needed to support work assignments.
• Respond to system failures and performance events by taking appropriate measures to reduce system downtime.