Cambia Health Solutions

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

Consultant

• 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

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.

Membership Administrator I - III, DOE

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

Policy and Implementation Analyst

Clinical Quality Consultant, Medicare

Medicare Clinical Quality Consultant

Membership Administrator I - III, DOE

Clinical Business Enablement Manager