Cambia Health Solutions

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.

Technical Project Manager IV

Program Manager

• Leads development and execution of compliance, quality, and delegation policies while designing and implementing division and corporate-level projects related to accreditation and delegation activities
• Establishes long-term departmental goals in conjunction with division leadership, maintains quality management frameworks that support continuous improvement culture, and drives best practice adoption across all business functions
• Communicates and interprets laws, regulatory procedures, and accreditation standards while ensuring legislative, regulatory, and accreditation changes are promptly identified and implemented across the organization
• Develops, maintains, and revises policies, procedures, and audit tools for oversight of delegated functions including credentialing, utilization management, case management, appeals, claims, and network management
• Conducts periodic oversight reviews of delegated entities, prepares final reports identifying deficiencies, develops corrective action plans with timelines, and escalates mandatory standard deficiencies while monitoring entity performance
• Champions quality improvement best practices by mentoring team members in QI methodologies (Lean, Six Sigma, PDSA cycles), fostering data-driven decision making, and leading projects that drive measurable organizational transformation
• Collaborates with leadership and cross-functional teams to identify improvement opportunities, serves as primary quality management subject matter expert providing guidance across departments, and facilitates knowledge sharing and best practice dissemination
• Develops and executes quality management strategies aligned with organizational goals, monitors quality trends, analyzes performance data, and recommends corrective actions to senior leadership while ensuring regulatory compliance and driving innovation
• Manages financial targets, department budget, and workforce allocation while overseeing project plans to ensure deliverables meet compliance and regulatory standards
• Defines business requirements for delegation-related reporting and data systems, manages design and control of delegation reporting systems, and tracks corrective action plans from internal monitoring and external audits

Program Director – Accreditation and Delegation

Consultant

• Provide clinical decision-making based on best practices in applying evidence-based medicine process in determining medications that have best value for efficacy and safety.
• Provide coverage recommendations for medications subject to prior authorization, appeals, retrospective claim reviews, and audits based on applicable medication coverage policies, member benefit contracts, and provider contracts.
• Complete peer-to-peer conversations with external healthcare professionals.
• Develop position papers, medication coverage policies, formulary monographs and class reviews, and formulary coverage recommendations based on critical appraisal of the scientific literature and input from practicing physicians to ensure optimal clinical outcomes at most cost-effective level.
• Present and/or communicate clinical positions on medication analysis in clear, concise manner.

Clinical Pharmacist Consultant

• Partner with cross functional teams to develop, drive, and lead strategic initiatives to successfully meet Government Programs goals and objectives.
• Responsible for building trusting relationships between all stakeholders in provider incentive programs and Government Programs teams by understanding each team's vision, strategy and business objectives and establishing credibility as a trusted expert resource to influence positive outcomes.
• Act as Government Programs subject matter expert and primary point of contact for all Quality Incentive Programs (QIP) stakeholders and for providers with more complex QIP and provider incentives issues and questions.
• Collaborate with teams that support Network Management with Medicare-specific data and education, while maintaining responsibility for Provider Incentive Program development, related metrics, and program operations.
• Coordinate initiatives and bring people together across multiple locations and functions while working across a highly matrixed organization.
• Act as a liaison between QIP/provider incentives and Network Management to ensure transparency, effective communication and alignment.

Program Manager – Provider Incentives

Actuary

• Acquiring skills in Microsoft Office Suite, health plan data, and coding for model development and data queries.
• Creates, maintains, updates and reviews established data queries and models; may recommend methodology or process improvements.
• Accurately prepares, updates and reviews regular work products, including project code, analytic models, data visualizations, and associated documentation; actively collaborates with peers.
• Assembles deliverables for customers and drafts responses to customer questions.
• Performs peer review of technical work products and acceptance testing of new reports, programs, and models, following department and team quality assurance standards.
• Meets established project deadlines; informs manager of work progress, new requests, and conflicts.
• Regular progress on passing actuarial exams to achieve actuarial credentials (ASA, MAAA).
• Effectively manages work and study time; contributes to own development plan.

Assistant Actuarial Analyst – Cost of Care Analytics

QA Engineer

• Direct, develop and lead the staff accountable for providing Health Plan Operation Quality Assurance Auditing and Reporting.
• Analyze and report audit results using graphs/trending in order to highlight and prioritize quality improvement opportunities.
• Identify error trends and work with business areas to reduce repeat errors.
• Collaborate with Claims, GMA, and Member and Provider Experience, and other divisions to implement corrective action plans.
• Prepare requests for new or changes to existing audit sampling methods and procedures.
• Optimize audit processes by leveraging technology where possible.
• Ensure hiring, performance evaluations, training and employee development promotes improved production and efficiency along with employee satisfaction.

Manager, QA and Reporting

Customer Support

• Serve as your callers’ guide and advocate, tackling tricky issues and answering questions about benefits, claims and eligibility.
• Roll up your sleeves and do the necessary research to find answers when you don’t have them.
• Bring a positive and professional approach to providing every caller with accurate, compliant information.
• Tailor your communications to meet each caller's unique needs.
• Stay one step ahead by spotting and addressing potentially difficult issues before they arise.
• Prioritize caller satisfaction while representing Cambia’s mission and values.
• Seek opportunities to collaborate and improve your skills through feedback and learning.

Temporary Customer Service Professional

• Expertise in insurance data, Microsoft Office Suite, and coding for model development and data queries.
• Manages regular team projects, workplans and documentation; actively collaborates with peers; may delegate to junior team members.
• Develops new methodologies; recommends methodology, assumptions, or process improvements to team management; may perform actuarial certification duties.
• Presents results to customers; effectively develops and reviews written responses to complex regulator or customer questions.
• Demonstrated success with personal and team project management; develops workplans and documentation.
• Performs peer review of regular and ad hoc work products, following department and team quality assurance standards; understands risk level of work products; ensures compliance with applicable Actuarial Standards of Practice.
• Effectively manages work and study time; actively manages own development plan.

Actuarial Analyst, Commercial Risk Adjustment

Financial Planning and Analysis

• Serves as a trusted finance business partner by providing financial guidance and support.
• Builds budgets, forecasts, conducts variance analysis and reporting.
• Prepares financial analysis for new business opportunities, proposals, contracts, or product development.
• Supports cost savings and process improvement efforts; provides financial governance and oversight.
• Develops complex financial models and analysis using advanced analytical techniques and financial systems; provides business alternatives to complex issues.

Lead Strategic Finance Analyst

Risk

• Attract, develop and retain the best talent for Cambia; provide effective leadership and oversight to get the best long-term performance from the team.
• Lead the development, planning, implementation and oversight of the performance of member engagement programs, including in-home assessments, direct scheduling with PCPs, mail or digital campaigns.
• Collaborate with other member-facing functions to ensure a coordinated approach that engages the member and improves health outcomes and member satisfaction.
• Proactively develop KPIs, reporting and tools needed to understand drivers of success or limitations and solve problems; collaborate with Risk Adjustment analytics, Actuary and other areas.
• Create a long-range planning function for risk adjustment to ensure appropriate strategic direction and assist the VP, Risk Adjustment in setting expectations for accurate risk coding.
• Lead staff providing planning, implementation and KPI reporting support for new strategic initiatives and executive reporting throughout Cambia.
• Manage relationships with third-party service providers and lead within a matrix organization.
• Provide direction to your team, engage them towards common goals and create a positive experience that helps people flourish.

Assistant Director – Risk Adjustment, Member Engagement and Planning

• Perform technical, analytical and support functions to help the division and the company meet its goals
• Combine academic experience with technical and analytical skills to support actuarial division
• Potential in-person/hybrid/remote work within Oregon, Washington, Idaho, or Utah
• Preference for in-person availability 1-3 days/week in Portland, OR or Renton, WA
• Participate in projects tracking and reporting on financial and risk positions within the company
• Support strategic goals of the corporation through actuarial analysis

Actuarial Intern

Analyst

• Use medical coding knowledge and experience to evaluate, recommend and implement clinical editing solutions to assure accurate outcomes consistent with medical and reimbursement policy and financial targets.
• Develop and execute implementation plans including system updates, business process changes and timely communication.
• Develop, maintain and publish reimbursement policy and online reference materials and technical documentation.
• Facilitate development, understanding and documentation of business requirements related to policy implementation and clinical editing.
• Perform analysis in the design and implementation plans to support new and revised medical and reimbursement policies.
• Coordinate implementation of new and revised online reference materials and technical documentation.
• Communicate policy and edit decisions to internal and external customers in a clear and concise manner.
• Serve as primary support for coding questions across Cambia and ensure coding decision-making is consistent, clinically appropriate and thoroughly documented.
• Apply coding expertise and judgment to assure medically appropriate and accurate claims adjudication.

Policy and Implementation Analyst

• Develops and maintains required quality program documents, including standardized quality management plans to ensure regulatory and accreditation compliance.
• Serves as point of contact coordinating with accreditation entities and business partners for compliance with accreditation and/or performance measurement requirements.
• Prepares the enterprise for accreditation and/or performance measurement submissions and reviews.
• Acts as subject matter expert for applicable accreditation standards and measurement requirements.
• Recommends improvements or remediation to business units for accreditation/reporting compliance and improvement programs.
• Monitors accreditation/measurement risks and identifies mitigation opportunities.
• Compiles information for internal use and external audits and maintains relevant records.
• Assists with development and maintenance of required quality program documents and reporting to quality committee and management.
• Manages and coordinates quality committees, including scheduling, workflows, minutes and reporting.
• Works with clinical and operational areas to develop performance metrics and tracking systems for health quality improvement.
• Identifies areas for improvement and implements interventions or corrective action plans.
• Keeps leaders informed through regular written and verbal project status communications.
• Handles complex quality initiatives and provides training to new team members and colleagues across the organization.
• Work from home (telecommute) within Oregon, Washington, Idaho or Utah; multiple office locations listed (e.g., Portland, OR; Salt Lake City, UT).

Clinical Quality Consultant, Medicare

Medicare Clinical Quality Consultant

Manager

• Strategic Leadership & Planning: Collaborates with division leadership to establish strategic vision and long-term departmental goals while maintaining operational agility
• Process Innovation & Value Stream Optimization: Champions development and implementation of innovative processes that enhance clinical operations, member experience, provider satisfaction, and care delivery effectiveness
• Business Intelligence & Performance Management: Proactively gathers insights from operational systems, members, providers, and stakeholders to establish data-driven, prioritized operational solutions
• Business Case Development & Requirements Management: Facilitates comprehensive business case development for strategic projects, including solution analysis, vendor engagement, financial analysis, and detailed business requirements
• Strategic Communication & Analytics: Develops compelling, data-driven narratives through advanced analytics, business case scenarios, and executive presentations that influence strategic decision-making across complex, highly interfaced, and rapidly evolving technical environments
• Team Leadership & Development: Provides comprehensive people leadership including performance management, talent development, recruitment, coaching, and retention strategies for a distributed team of clinical business analysts and process improvement specialists

Clinical Business Enablement Manager

Administration

• Process enrollment applications for individuals and groups, calculating eligibility data, effective dates, and entering member information consistent with contracts.
• Review and maintain account changes including effective dates, additions/deletions of members, and verify information through calls to employers, subscribers, or carriers as needed.
• Provide customer service through written correspondence and phone inquiries, making necessary corrections while ensuring member confidentiality.
• Perform eligibility and reconciliation tasks accurately and timely, including generating and reviewing billings, processing cash, and monitoring aged accounts to meet corporate standards.
• Order and audit member cards for accuracy, including corporate logos, lines of business co-pay, PCP, and member card comments.
• Apply corporate underwriting guidelines, governmental regulations, and updated policies to ensure compliance with federal, state, BCBSA and accreditation requirements.
• Coordinate electronic data transfer with external entities including CMS, employer groups, agents, and vendors; assist with system testing as needed.
• Support team operations by providing phone coverage, assisting with clerical tasks, participating in training, and working overtime when required.