Cambia Health Solutions

Executive Assistant

• Provide comprehensive executive administrative support, including drafting, editing, proofreading, formatting, and preparing correspondence, reports, presentations, meeting materials, and memoranda
• Manage executive communications and stakeholder interactions, prioritizing requests, routing inquiries, resolving routine matters, and escalating issues appropriately
• Manage follow-up communications, records, scheduling, office coordination, and workflow organization
• Handle sensitive information appropriately and ensure timely responses
• Prepare meeting agendas, capture decisions and action items, distribute follow-up materials, and support executive, leadership, and Board-related meetings
• Maintain accurate expense records and compile expense reports
• Support budget, expense, invoice, and operational reporting processes
• Strategically manage executive calendars, leadership meeting cadence, travel logistics, and related arrangements
• Draft correspondence, memoranda, reports, and presentation materials on behalf of or in support of executives
• Coordinate special projects and executive priorities, including meetings, conferences, events, presentations, reports, research, data compilation, and follow-up tracking
• Collaborate with the Administrative and Executive Assistant team and supported executives
• Provide backup support to other administrative team members as needed

Account Executive

• Analyze data to identify trends, opportunities, and challenges, and develop dashboards, reports, and metrics to track KPIs
• Collaborate with cross-functional teams to identify process improvement opportunities and develop effective solutions
• Manage small-scale projects and operational initiatives, adapting quickly to ad hoc assignments as they arise
• Document business processes, procedures, and requirements, including methods used to generate work output
• Apply knowledge of how departments work together to support effective organizational operations
• Contribute to team and departmental goals by managing multiple, often shifting objectives across diverse domain areas
• Partner with stakeholders to ensure analytics and reporting meet business needs for operational management and strategic decision-making
• Support change management and communications efforts related to process and operational improvements

Sales Performance Consultant

Program Manager

• Develops and launches complex cross-market programs supporting Provider Partnership Innovation.
• Manages and drives execution to support specialty Alternative Payment Models.
• Oversees the complete program lifecycle from development to operational sustainment.
• Supports and leads specialty programs including ongoing program management, program efficiency identification, and overall program execution.
• Ensures successful outcomes for members, providers, and employers.
• Represents Network Innovations in various forums and provides thought leadership for strategic program development.
• Leads Alternative Payment Model program development and integration activities including strategy, design, architecture, quality assurance, customer experience, and operational sustainment.
• Serves as key point of contact with strategic vendors while facilitating operational and strategic interactions with internal and third-party stakeholders.
• Identifies critical program risks and issues, drives resolution, and ensures requirements and dependencies are communicated to relevant stakeholders.

Program Director, Network Innovations

Procurement

• Prepares, configures, and maintains provider contract documents and templates in the contract management system.
• Conducts peer reviews and system testing of documents, templates, and configurations prior to production deployment.
• Implements and coordinates provider contracts and reimbursement with Provider Operations, Provider Pricing, and Provider Enrollment staff.
• Works cross-functionally with Network Management, Legal, and Regulatory Compliance teams to draft, coordinate, file, and revise provider contracts.
• Serves as the central point of contact for contract management system training, troubleshooting, and support.
• Maintains the integrity and accuracy of the provider contract database and repository.
• Supports internal and external audits, triages claims and audit inquiries, processes Single Case Agreements, and assists with mass mailings across all Plans.
• Develops and maintains contract policies, procedures, and desk references, enforces business requirements and standards.

Provider Contract Management Specialist

General

• Lead ongoing benefit development activities, including auditing complex benefit contracts and overseeing benefit change proposals to ensure compliance with state and federal laws.
• Track, analyze, and present regulatory updates to the Product Platform Team, and respond to inquiries from regulators regarding benefit design and compliance.
• Partner with cross-functional teams — including Product Development, Sales, Actuarial, and Marketing Communications — to implement, communicate, and monitor benefit-related activities.
• Lead the Medicare benefit design bid submission process to CMS for the Medicare PPO line of business, including competitive research and benefit analysis.
• Analyze competitive benefit trends and communicate strategic implications to internal management to help drive the product development process.
• Prepare and deliver benefit presentations and training to internal and external audiences, and respond to RFP/RFI proposals regarding benefit information and design.
• As a member of our strong leadership community, provide direction to your team, engage them towards common goals, and create a positive experience that helps people flourish.

Benefit Development Specialist II

Pharmacist

• Conduct post-service audits to ensure billing accuracy
• Analyze billings for consistency with medical records and reimbursement policies
• Perform projects as requested by supervisors
• Prioritize work and coordinate activities to ensure timely record reviews and audits
• Evaluate and interpret drug administration and treatment information when needed
• Ensure all work meets corporate standards and complies with federal, state, and accreditation regulations
• Maintain organized reference documents and follow established policies and procedures
• Meet production requirements and quality standards for all assigned work
• Support department efficiency through flexibility and cross-training on various functions

Clinical Inpatient Pharmacy Technician, Audit & Review

Pricing Analyst

• Collaborate closely with Provider Services, Network Management, corporate business support, operations staff and others to ensure negotiated provider and institutional payments are implemented correctly and promptly.
• Load and maintain rates in appropriate system files to accurately price professional and facility claims for contracted providers, ensuring all programming changes are implemented correctly and timely.
• Research, analyze, and implement provider reimbursement methodologies industry-wide while supporting the development of new reimbursement strategies.
• Responsible for creating all payment exhibits attached to provider contracts and maintaining updates to CPT, DRG, AP-DRG, HCPCS, per diem, ICD-9, and HCPCS coding changes.
• Research contract and pricing issues that may result in over or underpayments, recommend corrective actions, and coordinate implementation of solutions.
• Actively participate in the local Regence Reimbursement Subcommittee and represent the Regence plan at various state or regional meetings and committees.

Pricing and Reimbursement Analyst I/II

Investigator

• Receives, analyzes and coordinates fraud and abuse complaints from internal sources (customer services, claims processing, underwriting, professional affairs) and external sources (members, providers, state and federal regulatory agencies, law enforcement), then conducts and coordinates moderately complex investigations with expertise across various case types, participating in post-audit exit interviews where appropriate.
• Provides accurate accounting of recovered funds from audit activities, criminal or civil convictions and settlements, demonstrating continuing success in settlement, recovery and collection activities related to fraudulent activity.
• Maintains continuing education through anti-fraud and legal issue seminars, holds at least one professional credential (CPC, CPC-H or CPC-P), reviews pertinent articles and regulatory requirements, and provides post-audit education to providers to correct discrepancies, and trains new Investigators and other Cambia employees in detection of abusive or fraudulent billing practices.
• Assists with maintenance of audit and investigation files, formulation of company policies addressing loss exposures and solutions, and maintains extensive contact with the provider community in both educational and potentially confrontational or adversarial investigative roles.
• Issues audit findings and prepayment claim determinations, including maintaining clear documentation of the basis of findings and determinations, and maintaining the required professional judgment to support and deliver them independently.
• Represents company at external and internal meetings dealing with fraud and abuse issues and litigation proceedings, testifies in court as required, and develops professional working relationships with various associations and agencies for detection of local and national fraud and abuse schemes.
• Conducts witness and target interviews, identifying and analyzing evidence, examining records to verify document authenticity, preparing and evaluating investigation reports, providing information for affidavit preparation, and maintaining communications with law enforcement and regulatory agencies to present case findings for further investigation, prosecution or administrative remedies.

Special Investigations Unit Investigator II – III

AI Research Scientist

• Drive innovation across multiple business areas such as clinical care delivery, customer experience, and payment integrity.
• Serve as a technical leader and strategic advisor.
• Personally architect and build sophisticated AI solutions while mentoring junior team members.
• Actively contributing code, developing models, and solving complex technical problems alongside your team.
• Lead cross-functional initiatives, establish best practices, and serve as a subject matter expert to both technical and business stakeholders.
• Partner with business leaders to identify high-impact AI opportunities and translate ambiguous business challenges into actionable AI initiatives with clear success criteria.
• Design comprehensive experimentation strategies including A/B testing, causal inference, and statistical validation.

Senior AI Scientist

Clinical Operations

• Develops, prioritizes, implements, and optimizes pharmacy quality, affordability, and medication management programs, including Medicare Stars, HEDIS, and other clinical initiatives.
• Identifies opportunities to improve program performance, member outcomes, and operational effectiveness.
• Builds partnerships and leads cross-functional initiatives involving Pharmacy, Quality, Analytics, Product, Provider Enablement, Care Management, Operations, Network Management, and external vendors to achieve organizational goals.
• Assures service levels and activities meet client service level agreements, as well as contractual obligations and compliance, such as state, federal, and CMS regulations or specific member contracts, with service guarantees.
• Provides routine and/or intermittent reporting and analysis as appropriate of clinical program activities that fall under their oversight.
• Ensure continuous quality assurance inclusive of documented policies, procedures, and workflows for all programs.
• Provides leadership and mentorship to direct reports, including clinical and non-clinical staff, through development and tracking of performance goals and objectives, as well as through quarterly performance conversations.
• Prioritizes and manages work activities of clinical pharmacist consultant staff.
• Collaborates with the Pharmacy Directors, VPs, and other leadership in coordinating corporate-wide activities related to the appropriate use of medications, improved quality related to medication therapy, promotion of cost-effective prescribing, and reduction in short-term and long-term overall costs to internal and external clients.
• Provides strategic oversight of assigned vendor relationships, including implementation, performance monitoring, governance, operational optimization, and evaluation of new opportunities that support organizational priorities.
• Identifies emerging trends, regulatory changes, and innovation opportunities that improve quality outcomes, affordability, member experience, and business performance.
• Handles all management level responsibilities for staff, hiring, firing, coaching, counseling, and retention.
• Manages financial targets and department budget, authorizes expenditures, monitors workforce allocation and resources, and oversees project plans.