Cambia Health Solutions

Data Analyst

• Analyze data and prepare comprehensive reports related to health care services, utilization, costs, trends, enrollment, incentives, and revenue across providers, members, networks, groups, products, and lines of business
• Create and modify complex reports and underlying SQL queries, including BOE universes and automated enterprise dashboards, while identifying needed reporting and directing assembly as appropriate
• Perform statistical analysis and data modeling based on user requests, making strategic recommendations that support business objectives
• Validate own work and complex reporting produced within and outside the department, providing final sign-off and defining procedures, processes, and tools to automate validation
• Maintain existing and develop new information reporting systems to support requirements of internal and external users, evaluating impacts of new products, systems, and work processes on data and reporting systems
• Collaborate with departments responsible for transaction systems to ensure reporting data is captured accurately and that data integrity and reliability are maintained throughout the data warehouse
• Develop and execute balancing and validation routines to ensure data warehouse updates are complete, accurate, and maintain integrity
• Assist business analysts across departments with data interpretation and appropriate uses of data tools and reporting algorithms, providing training in query and report preparation to improve consistency
• Make decisions on issues with significant financial impact and risk to the corporation, proactively identifying concerns and bringing them to management attention
• Communicate analysis results and recommendations in both verbal and written form to stakeholders, determining reporting requirements through ongoing dialogue with information users, and may mentor or lead other analysts on projects

Pharmacy Data Analyst I, II, III

Customer Support

• Completes non-clinical tasks assigned by BH UM Clinicians related to case completion, care coordination, and discharge planning, including initiating referrals to care management (CM) and single case agreements (SCA) as needed.
• Communicates effectively and professionally within and across teams, and with providers to prompt concurrent review submissions, convey UM determinations, cancellations, and other necessary communications in compliance with all regulatory and quality requirements.
• Facilitates written and verbal notifications to providers to request medical records and additional information, ensuring all communications meet regulatory standards and timeliness requirements.
• Adheres to all performance criteria including timeliness, production, and quality standards while performing detailed research and problem-solving using sound decision-making skills to ensure BH UM case accuracy and completeness.
• Exhibits excellent time management and organizational skills to ensure all UM activities meet regulatory and quality requirements, keeping reference documents, policies, and procedures readily accessible.
• Follows strict guidelines to ensure all work meets corporate standards for accuracy, timeliness, quality, and compliance with federal, state, BCBSA, and accreditation regulations.
• Demonstrates and promotes a professional and ethical work environment with all stakeholders while contributing to continuous improvement by identifying opportunities for improvement within systems and workflows, and may assist with systems testing if applicable.

Behavioral Health Utilization Management Clinical Support Specialist

Client Partner

• Provide clinical guidance, reporting, program recommendations and benefit strategies.
• Works in collaboration with the Pharmacy Sales and Account Management team.
• Identifies, leads, and measures the impact of pharmacy program opportunities that impact client cost, utilization, and quality metrics.
• Synthesizes client utilization data, benefit designs, employee value proposition goals, and pharmacy clinical programs.
• Provides client specific recommendations to improve pharmacy program performance.
• Provides professional and clinical expertise for Pharmacy clients in making clinical decisions based on best practices.
• Assists the Pharmacy Sales and Account Management Team in planning, developing, and implementing clinical strategies for Pharmacy clients.
• Collect, analyze, interpret, and forecast healthcare cost information based on prescribing patterns and medication utilization reports.
• Deliver creative thinking and leadership to accomplish quality improvement and cost-effective prescription drug program goals.

Clinical Pharmacist, Client Manager

AI Engineer

• Designing, implementing, and maintaining AI operations infrastructure for AI applications.
• Collaborating with ML scientists, engineers and stakeholders for effective AI model integration.
• Automating workflows, optimizing performance, and monitoring model outcomes.
• Building rapid GenAI prototypes to accelerate innovation.
• Advancing AI capabilities and supporting data-driven decision-making.

Platform Engineer

• Design, Build and Maintain scalable data pipelines using ETL and ELT on cloud platforms
• Develop Data Integration Solutions to connect various data sources to a single unified data source while ensuring data architecture that supports a single source of truth
• Develop efficient, effective, and maintainable program and system solutions to solve complex business problems
• Develop automated workflows for data ingestion, transformation, and applications integration
• Writes efficient code in languages such as SQL and Python.
• Responsible for supporting our Product and Business partners by researching, identifying and resolving highly technical programming problems
• Meets established deadlines while maintaining a high level of quality of work
• Performs testing and documents the results
• Adheres to policies, procedures, and standards in place within IT/Engineering as well as all corporate policies, procedures and standards established by Cambia.

Data Platform Engineer – III

Claims Specialist

• Accurately apply contract benefits within guidelines and recognize incomplete or inappropriate claims.
• Recognize all policies and procedures that apply to claim and be able to quickly reference documentation for details.
• Make informed decisions regarding the disposition of claim; may include payment or denial of claim, or requests for further information.
• Lead the process to measure, track, and report all aggregate claims.
• Audit all aggregate claims onsite and off-site when needed based on set dollar threshold.
• Provide client audit reporting as needed.
• Manage inventory of claims while ensuring best practices and claim standards are met.
• Identify new opportunities to track and process claims more efficiently.
• Thoroughly document claims throughout the adjudication process so they can be understood by the team and for audit purposes.
• Analyze and investigate all claims, request supplementary documentation as necessary, in order to process or reprocess claims in a timely and accurate manner.

Stop Loss Claims Analyst

System Administrator

• Participates in a team environment for the installation, upgrade, and maintenance of new and existing computer systems, operating systems, and/or software applications.
• Manages service request queues and responds to customer issues in a timely manner, triaging, prioritizing, and resolving issues, escalating problems as appropriate.
• Installs, configures, and maintains computing systems and support software, including hardware setup, OS installation, patches, and performance tuning.
• Monitors system health and ensures maximum availability and reliability through proactive troubleshooting and maintenance.
• Researches and resolves software and hardware issues ranging from simple to complex, collaborating with vendors and support teams as needed.
• Shares technical knowledge to improve team performance and system efficiency, including mentoring other team members.

Systems Administrator II

Director

• Provides leadership for Claims production processing activities in the commercial claims service organization.
• Responsible for strengthening the organization’s effectiveness in claims processing by achieving satisfaction through fast and accurate claims processing.
• Works cooperatively with executives and management teams throughout Cambia to accomplish goals.
• Maintains a leadership team approach to resolve problems or issues of overall importance.
• Drives the effectiveness of the Claims organization through appropriate organizational structure, an effective work environment, regular employee communication, recognition and development.
• Continually strives toward increased customer satisfaction while increasing operational efficiency.
• Responsible for fiscal management, including budget preparation, expenditure control, and record keeping.
• Coordinates with the directors from all Regence Plans to continuously improve the cost, quality and effectiveness of Operations functions.

Assistant Director – Claims Production

Research Analyst

• Provide consultation on the design, testing and enhancement of corporate programs.
• Achieve actionable insights and solutions using analytical and statistical methods, project management and business knowledge.
• Research and evaluate programs and outcomes to determine performance against stated objectives.
• Document and communicate recommendations and solutions to business partners.
• Perform complex analyses on programs and initiatives and create visual representations and summary reports of findings.
• Develop meaningful dashboards and presentations that use information to inform and influence business activities and strategies.
• Collaborate with cross-functional teams to develop business cases and identify business problems.

Consulting Research Associate I – II

Auditor

• Performs Retrospective and Prospective chart reviews to ensure accurate risk adjustment reporting.
• Verifies and ensures the accuracy, completeness, specificity and appropriateness of provider-reported diagnosis codes based on medical record documentation.
• Reviews medical record information to identify complete and accurate diagnosis code capture based on CMS HCC categories.
• Identifies trends in provider coding and documentation and partners with Provider Education Consultants to develop intervention strategies.
• Supports and actively participates in process and quality improvement initiatives.
• Maintains knowledge of relevant regulatory mandates and ensures activities are in compliance with requirements.
• Consistently meets departmental performance and attendance requirements.
• Serves as a mentor to Risk Adjustment Auditor I staff.
• Assists with special projects such as risk mitigation reviews.
• Serves as subject matter resource regarding the risk adjustment process and diagnosis coding for risk adjustment.
• Monitors and interprets regulatory changes that may impact administration of the Risk Adjustment Program.
• Assists with implementation activities as a result of regulatory changes to the Program.

Risk Adjustment Auditor II

Analyst

• Provides consultation on the design, testing and enhancement of corporate programs.
• Achieves actionable insights and solutions using analytical and statistical methods, project management and business knowledge.
• Researches and evaluates programs and outcomes to determine performance against stated objectives.
• Documents and communicates recommendations and solutions to business partners.

Consulting Analyst, Associate

Systems Engineer

• Participate in the daily support, maintenance, and enhancement of existing systems
• Development, configuration, and delivery of new systems to support Cambia Core Strategies and Key Initiatives
• Assist in development of Business and Senior Business Analysts and back up Supervisor as required
• Perform in a project and staff leadership role
• Perform post implementation quality assurance, troubleshooting and issue resolution
• Monitor and implement continuous process and system improvements
• Develop and implement prudent Approach, Data Migration and Back-up plans for any given update
• Communicate to various partners (senior leadership, vendors, and other internal Cambia teams)

Business Systems Analyst Lead – Support Services

Business Analyst

• Gather, compile, and analyze competitive intelligence and market data in compliance with ethical standards, utilizing online databases, sales channels, and external partnerships.
• Analyze competitor value propositions, market trends, and consumer preferences through secondary research and both internal and external sources.
• Communicate findings and strategic recommendations to project owners and stakeholders across departments to inform business decisions.
• Lead and coordinate market intelligence projects independently, operating without day-to-day formal guidance.
• Collaborate with cross-functional teams to align divisional interests with corporate business partners.
• Respond to ad-hoc intelligence requests and provide timely competitor, product, and market data to improve company operations.

Market Insights Analyst

Technical Project Manager

• Manage work efforts from concept through close-out and support the management of work efforts of varying complexity and technical scope.
• Handle the largest and most complex of assignments and may lead teams of people to ensure work efforts are delivered on schedule and within budget.
• Satisfy agreed-upon customer requirements and specifications within the scope of the work effort.
• Responsible for monitoring and reporting on work effort tasks, deliverables, costs, resources, issues, changes, risks and quality assurance.
• Create and maintain plans and other documentation in compliance with established standards.
• Develop and maintain the overall work effort documentation library ensuring that all documentation is established, maintained and retained as necessary.
• Prepare status and other reports, and present information to organizational leadership, work teams, and client/customer groups.
• May act as ScrumMaster for one or more Agile teams.