Capital Blue Cross

Support Engineer

• Handle customer inquiries through multiple channels primarily inbound phone
• Conduct research and provide problem-solving support to Members, Providers, Brokers and Sales
• Ensure compliance with organizational and regulatory requirements
• Utilize manuals, online reference materials, Imaging, etc. to obtain information
• Monitor Vendor related inquiries utilizing various system generated reports

Client Services Support Analyst – Rx Calls

Consultant

• Responsible for planning and executing documentation/case audits (internal and external) for assigned unit
• Responsible for educating staff on findings, and the audit tool to ensure a consistent approach to documentation and case collaboration.
• Monthly, quarterly, annually and upon request, prepares written evaluation of quality and oversight activities for assigned unit(s) to ensure regulatory/accreditation/contract compliance
• Establishes appropriate benchmarks and analyzes reports to determine if utilization and quality performance are appropriate.
• Identify opportunities for improving processes and outcomes.
• Development and monitoring of corrective action plans and follow-up activities.
• Maintains appropriate documentation of records, reports, correspondence, training and additional quality and oversight activities
• Actively engages in Capital’s compliance activities, including that of any delegated UM vendors, if applicable
• Assists in ensuring that letters remain in compliance with accreditation and regulatory standards for Capital and any delegated UM vendors, if applicable for assigned unit.
• If applicable to assigned unit, development and implementation of various quality activities including: IRR question development and assessment for assigned unit staff, including development and education of identified areas of opportunity
• Perform routine mock audits for UM, both CMS and NCQA focused.
• Participates in all regulatory and accreditation reporting activities.

RN Clinical Quality and Oversight Consultant

Analyst

• Work with internal and external partners to identify and validate new provider concepts and scenarios through analysis of paid claims data, review of internal payment and medical policies, and any other pertinent information to support determination(s).
• Independently evaluate and analyze submitted claims to ensure the concepts/scenarios aligns with Capital book of business.
• Includes but not limited to: Research and analysis of applicable provider contract terms and rates
• Analysis of member benefits and utilization
• Analysis of overarching administrative regulations (Federal, State, BCBSA, etc.)
• Analysis of appropriate provider coding and billing practices and coding guidelines.
• Serve as a department lead for to present new edit concepts and issues to internal business areas.
• Communicate status updates verbally and in writing to impacted internal business areas.
• Identify new edit or solutions, projects risks, and contingencies.
• Conduct root cause analysis and identify process improvement opportunities.
• Build strong working relationships with internal and external customers.
• Summarize verbally and in writing, advanced analytical research, including claim analysis, which is understandable to the intended audience.
• Facilitate meetings including preparing agendas, minutes, and other documentation as needed.
• Communicate delays, risks, and impacts to both management and business areas.
• Ongoing business evaluation of vendor updates, but not limited to LCD reviews, and knowledge base updates (edits).

Payment Integrity Claims Editing Analyst

• Implement the population health framework for assigned customers and populations of focus
• Develop and maintain knowledge of current customer contract(s) and performance guarantees
• Maintain up-to-date knowledge of the customer’s specific resources
• Develop and maintain an effective working relationship by meeting regularly with customers
• Serve as a liaison between all parties to the population health initiative assigned
• Refer members to the appropriate programs to meet the member’s needs
• Integrate Triple Aim principals to improve member health outcomes and experience of care
• Identifies and reports quality of care issues in accordance with established departmental policies and procedures

Population Health Clinical Consultant, Registered Nurse

Network Operations

• Responsible for leading analyzation, evaluation, development and implementation of new and existing reimbursement policies
• Responsible for the development, implementation and ongoing oversight of a Reimbursement Policy Committee
• Responsible with resolving reimbursement policy issues that arise either during contract settlements
• Oversight of all Network-related projects to maintain focus on timely, on-budget deliveries
• Responsible with oversight of the identification and continuous improvement of network policies and procedures

Manager, Network Operations Improvement – Policy

Program Manager

• Analyze Medicare STARS performance metrics including HEDIS, CAHPS, HOS, and operational measures to identify trends, gaps, and opportunities.
• Lead or contribute to the forecasting of STARS ratings, using historical data, predictive modelling, and CMS methodology to project future performance.
• Translate STARS forecast insights into strategic initiatives to optimize performance and achieve targeted ratings.
• Collaborate with internal teams (Quality, Clinical, Operations, A&R, among others) to drive action plans based on performance and forecast data.
• Develop and maintain dashboards and performance tracking tools in Power BI and Excel to support ongoing monitoring and executive reporting.
• Write and optimize SQL queries to extract, manipulate, and analyze complex datasets from various sources.
• Use Python for automating data processing tasks, generating forecasts, and conducting advanced analyses as needed.
• Ensure accurate, timely reporting and alignment with evolving CMS requirements and regulatory updates.
• Support audits, internal reviews, and CMS data submissions with high attention to data quality and integrity.
• Collaborate with Actuarial to project and monitor the impact of the program on revenue for forecasting and financial statement accruals.
• Assist during the creation of processes, documentation, reporting infrastructure, SOPs, audits, etc.

Medicare Stars & Quality Program Analyst

Operations

• Providing analytical support to various business areas and customers
• Acts as subject matter expert providing technical and/or business knowledge to support decision making processes
• Collaborates on the development of Medical Value initiatives and business intelligence platforms
• Successfully delivers the design, development and implementation of analysis and research on cost and utilization trends

Senior Government Ops Business Consultant

• Serve as a department project lead for corporate and departmental initiatives, including those involving appeals & grievances reporting, claims operational enhancements, and regulatory changes.
• Provide written and verbal status updates, identify risks, perform root cause analyses, and recommend process improvements.
• Mentor less experienced staff, including informal coaching on reporting, appeals workflows, systems navigation, and documentation standards.

Senior Government Operations Analyst

IT Support

• Responsible for the development and implementation of Capital's Enterprise Architecture strategy
• Provides direction for the day to day operation support for CBC Enterprise Architecture
• Develops corporate strategies/plans related to CBC's EA direction and presents to senior management, board of directors and trading partners as needed
• Provides consulting support/service to the CBC business community regarding all technologies
• Reviews CBC's EA plans, practices and policies and ensures they are appropriately synchronized with its affiliates and other business/trading partners
• Develops strategies for the use of internally and cloud based technologies
• Develops strategies for QA, Agile and other cross functional needs
• Provides management of vendor relationships and contracts that support CBC's EC initiatives
• Ensures that corporate and unit budgets reflect and support EA initiatives
• Applies Human Resources policies and procedures in a consistent, equitable manner to ensure fair and equal treatment for staff

Director, Enterprise Architecture

• Responsible for planning and executing documentation/case audits (internal and external) for assigned unit (e.g. UM, CM, delegated vendor(s))
• Responsible for educating staff on findings, and the audit tool to ensure a consistent approach to documentation and case collaboration.
• Monthly, quarterly, annually and upon request, prepares written evaluation of quality and oversight activities for assigned unit(s) to ensure regulatory/accreditation/contract compliance.
• Establishes appropriate benchmarks and analyzes reports to determine if utilization and quality performance are appropriate.
• Identify opportunities for improving processes and outcomes.
• Development and monitoring of corrective action plans and follow-up activities.
• Maintains appropriate documentation of records, reports, correspondence, training and additional quality and oversight activities to ensure comprehensive tracking of documentation that meets both regulatory and accreditation standards, including for delegation when appropriate.
• Actively engages in Capital’s compliance activities, including that of any delegated UM vendors, if applicable.
• Monitors regulatory and accreditation standards for updates and proposes updates to Policy and Procedures as required.

Clinical Quality and Oversight Consultant

Director

• Lead all aspects of Capital’s network contracting activities related to traditional FFS and value-based reimbursement methodologies for the network portfolio; including facility, ancillary, and professional providers.
• Responsible for direct oversight, management and training of the contracting staff reporting to this position.
• Responsible for the negotiation of contract terms, unit cost management, and strategic network-inspired product designs - such as, tiered or narrow networks etc.
• Lead the transformation of Capital’s existing network from a primarily fee-for-service driven model to a model to value based programs that align with the Triple Aim objectives (satisfaction, quality, and cost).
• Provide leadership in evaluating opportunities to expand or change the network to meet company goals.

Director, Network Contracting

Compliance

• Participate in a variety of experiences through meaningful work assignments, observation opportunities, and social interactions.
• Complete a service project with one of community partners.
• Participate in ongoing company initiatives and translate classroom learning into fresh perspectives.
• Formally present outcomes of experience to leadership team.
• Receive periodic feedback and professional development programming.

Compliance and Privacy Intern

• Participate in a variety of experiences through meaningful work assignments, observation opportunities, and social interactions.
• Complete a service project with one of our community partners.
• Participate in ongoing company initiatives and be challenged to translate classroom learning into fresh perspectives.
• Present the outcomes of their experience to executive and extended leadership team.
• Receive periodic feedback and professional development programming from Capital team members.
• Network with Capital Blue Cross staff and participate in company-wide learning events.

Corporate Compliance Intern

Artificial Intelligence

• Develop and execute AI and automation roadmaps aligned with business objectives and digital transformation initiatives
• Establish a clear roadmap for automation capabilities including RPA, intelligent document processing, machine learning, generative AI, and workflow automation.
• Partner with senior executives to evangelize AI capabilities, guide investment decisions, and promote responsible AI adoption.
• Collaborate with business leaders to identify opportunities where automation and AI can improve efficiency, reduce manual effort, improve accuracy, and enhance customer experience.
• Conduct ROI assessments, business case development, value tracking, and continuous improvement evaluations.
• Help with evaluation, selection, and integration of AI platforms, tools, and technologies.
• Oversee the end-to-end design, development, testing, and deployment of automation solutions leveraging: RPA tools (e.g., UiPath, Automation Anywhere, Blue Prism, Salesforce) AI/ML platforms and cloud-based AI services (Azure, AWS, Google, etc.) LLM-based automation and generative AI capabilities Integration with core payer platforms (e.g., Facets, TruCare) Drive a culture of innovation, continuous improvement, and AI literacy throughout the organization
• Build and lead a high-performing team of automation engineers, AI specialists, data scientists, and business analysts.
• Foster a culture of innovation, experimentation, and continuous learning.
• Partner closely with Enterprise Architecture, Data & Analytics, Cybersecurity, and Agile product teams to ensure cohesive delivery.
• Partner with AI Governance council to establish and maintain governance frameworks, best practices, and ethical guidelines for responsible AI development and deployment, ensuring transparency, fairness, and regulatory alignment.

Director – AI and Automation

• Accountable for the daily operations of Capital’s suite of care management, utilization management and vendor solutions.
• This includes coordinating system upgrades, engineering new use cases or workflows, liaising with vendors, clearly documenting requirements and testing changes before production.
• Design and develop the business strategy and requirements needed to monitor and dynamically manage member clinical interventions across multiple current and future use cases.
• Accountable for engineering systems that can trigger the right clinical interventions for the right member at the right time.
• Partners with operations leaders to plan for and incorporate AI/ML and automation solutions where appropriate and updates strategy as vendor capabilities evolve.
• Works with enterprise leadership to ensure that requests are appropriately prioritized and cross-functional dependencies are identified and managed.
• Responsible for coordinating resources and aligning on product changes by maintaining an intake, triage and strategic roadmap project queue.
• Regularly reports on project status, risks and resource capacity to inform dynamic adjustments to project priority and timeline.
• Maintains project portfolio status and visibility across all impacted stakeholders.
• Partners with analytics colleagues to ensure that data emanating from population health applications is appropriately governed, and that clinical workflows are generating the expected discrete data to support analytics and reporting.
• Partners with operations management to develop reports and embed insights that aid productivity management and improve the efficiency of clinical workflows.
• Supports the bi-directional movement of files to and from vendors to support effective member engagement, minimize administrative waste, and maximize outcomes across Quality, Risk and Total Cost of Care.
• Responsible for evaluating the impact of regulatory changes on technology solutions and workflows, including risk mitigation and compliance with CMS, NCQA, FEP, BCBSA or other regulatory body mandates.
• Develops and calibrates agile workflows to manage team productivity and maintain high quality user experience for the clinical team members.