Capital Blue Cross

Pharmacist

• Provide leadership, direction and oversight for pharmacy sales and account management
• Develop and implement strategies relating to Pharmacy sales and account management
• Responsible for developing, implementing and maintaining a strategic pharmacy sales and customer relations approach for our brokers, groups, and members
• Responsible for ensuring that our customers’ and members’ expectations around pharmacy are matched by our corporate and divisional strategies and goals
• Develop and direct the formulation and implementation of short and long-range strategies in support of Capital’s pharmacy sales growth and retention goals
• Responsibilities will include responding to Requests for Proposals (RFP’s)
• Help integrate pharmacy benefit management into our Health Plan Business by serving as the external Subject Matter Expert for pharmacy benefits
• Responsible for the management of staff and resources including hiring, development, coaching and counseling and annual performance reviews for direct reports
• Partner with PBM Sales team (new and renewal) to monitor opportunities and deliver results

Manager, Pharmacy Account Support

Analyst

• Functions as a primary support for teams responsible for the development and maintenance of Network pricing schedules and facility reimbursement
• Makes recommendations on the feasibility of procedural changes
• Acts as an advisor for the Network Provider Contracting and Network Analytics and Contract Support teams
• to answer questions relating to payment and system configuration
• Researches and analyzes Network reimbursement/payment issues and develops recommendations to improve
• Coordinates the configuration and implementation of non-complex professional and facility provider pricing schedules

Network Reimbursement Analyst II

Accounting Manager

• Records daily/monthly Miscellaneous Invoices for Capital Blue Cross and Subsidiaries within Workday
• Verifies the accuracy of the General Ledger coding provided prior to creating the invoice
• Generates and distributes invoices, weekly aging reports and statements to internal and external personnel
• Responsible for the daily tracking and recording of Alternate Payee Affidavits into an Access Database
• Communicates verbally or in writing with Capital's banks as needed in regard to bank statements, bank adjustments, forgery affidavits and other related documents

Accounting Clerk II

Compliance

• Supports internal customers by assisting them to understand regulatory and other requirements, implement compliant solutions and establish adequate monitoring mechanisms.
• Receives, logs, researches, analyzes, and responds to compliance inquiries and concerns that are related to regulatory and other requirements and guidance, as well as other compliance issues.
• Administers the Incident Reporting and Corrective Action process to ensure that compliance issues are identified, addressed, and resolved on a timely basis, using an approach that prevents future reoccurrence of similar issues.
• Participates in projects or committees aimed at implementing operational, technological, and other changes to achieve or maintain compliance with regulatory and other requirements.
• Conducts oversight activities of First-tier, Downstream, and Related Entities (FDRs), Delegated Downstream Entities (DDEs) and/or CHIP subcontractors, as applicable.
• Develops, maintains, and oversees compliance monitoring activities and strategies.
• Provides support during internal and external audits, as appropriate, and monitors the completion of corrective action plans.
• Reviews, analyzes and evaluates regulations and guidance to determine its impact and affected business areas.
• Prepares, coordinates and/or submits required regulatory filings, attestations or reports.
• Develops and maintains internal departmental policies and procedures and provides recommendations to business areas in their development and implementation of their own policies and procedures.
• Administers or supports processes owned by the department such as Corporate Policy Administration, Conflict of Interest Disclosures, Compliance Training, Regulatory Intake, Compliance Monitoring and Exclusion Screening, among others.
• Performs other tasks as assigned by management, the Compliance Officer or the Chief Compliance Officer.

Compliance Specialist

Risk

• Provides administrative support to the Board of Directors by maintaining attendance records
• Tracks Board and Committee calendars to ensure adequate preparation in advance of meetings and appropriate post-meeting follow-up
• Maintains accurate records on current Directors
• Acts as a project manager for the annual Board of Directors Disclosure Statement process, Self-Assessments, and Succession Planning process
• Assists with production of the weekly News Update from CEO to Board of Directors
• Coordinates logistics for Board and Committee meetings and off-site retreats
• Remains available and on hand prior to and during all Board and Committee meetings to assist in all matters and resolve any issues
• Coordinates research in support of Director Inquiries of an administrative or support nature
• Responsible for maintaining the documents on the Board portal
• Manages and coordinates multiple priorities to ensure appropriate development, approval, publication, retention and destruction of materials.

Corporate Governance Coordinator

Manager

• Lead strategic provider partnerships to negotiate contracts
• Execute contract negotiations and drive provider network strategy
• Implement innovative reimbursement models
• Ensure contracts meet regulatory, financial, and operational requirements
• Collaborate across internal teams and support performance programs like STARS

Provider Contract Manager

• Participate in Department projects and process improvement/collaboration activities.
• Communicate project status updates (verbally and in writing).
• Capture necessary documentation related to activities.
• Identify project risks and contingencies.
• Conduct root cause analysis.
• Identify and support process improvement opportunities.
• Build strong working relationships with internal and external partners.
• Facilitate meetings and prepare necessary documents such as agendas, minutes, etc.
• Support department tracking through SharePoint sites, Teams, etc.
• Keep management and business areas informed about delays, risks and impacts.
• Collaborate with Operations Analytics & Reporting as required to support project/process improvement activities.
• Develop high level technical knowledge, including an understanding of Operations data sources if required.
• Ability to document and understand business reporting requirements as needed.

Continuous Improvement Analyst

IT Support

• Conduct end-to-end audits of provider charge masters (CDM) and associated claims to evaluate billing accuracy, rate structures, and adherence to contractual and regulatory requirements.
• Review and analyze provider chargemaster data to identify outliers, inconsistencies, or policy violations.
• Assist in the development and maintenance of audit models, dashboards, and templates to support enterprise audit functions.
• Prepare audit summaries with findings and recommendations.
• Support provider communications regarding audit findings and recommend process improvements.
• Maintain current knowledge of CMS guidelines, payer policies, and healthcare billing standards (UB-04, CPT, HCPCS, revenue codes).
• Contribute to reimbursement and contract review projects.

Provider Audit Specialist

• Responsible for the coordination of services for members who meet established criteria
• Use a collaborative process to assess Member needs and develop a plan of care
• Monitor progress, evaluate Member status, and fully document care management process
• Address medical, psychosocial, clinical needs, and behavioral health needs
• Provide counseling and referrals to community/local/state programs

RN Care Manager – Oncology

Administration

• Responsible for administration of all aspects of stop loss account business
• Expected to meet or exceed departmental metrics for key production responsibilities
• Provides excellent customer service and sales support
• Assists in the implementation of new products and initiatives
• Drives implementation of process improvements to existing administrative processes

Stop Loss Administration Specialist

• Monitor team performance against Key Performance Indicators (KPIs) and develop action plans to maintain/improve performance
• Provide coaching and/or mentoring for front-line staff to ensure performance expectations and regulatory requirements are met
• Perform root cause analysis to Identify trends and top drivers related to member dissatisfaction and develop action plans to reduce member complaints
• Perform research and analysis relative to current or future service functions and present recommendations for process improvements
• Monitor budget vs. actual expense reports each month and contribute to annual budget input process

Manager, Medicare Member Services

Systems Engineer

• Work with a cross-functional team on large scale projects.
• Identify potential projects risks and contingencies.
• Elicit and document detailed business requirements to support system and process changes for cross-functional projects.
• Considers root cause analysis and identifies process improvement opportunities.
• Apply practical application and industry knowledge to decision making and strategic initiatives.
• Make complete technical and business process recommendations including ROI, estimated time required and other documentation that supports the project life cycle.
• Serve as liaison between business process experts and technology experts in order to elicit business requirements and translate to technical teams.
• Develop the test strategy and planning documents.
• Coordinate and communicate test strategy to project sponsors, and management.
• Ability to serve as a Test Lead on complex projects and provide test execution support as needed.
• Ability to write test plans and enter into defined testing tools.
• Assign testing tasks as needed to project testers.
• Monitor activities assigned to testers and ensure testing is completed by the due date.
• Review and coordinate testing with business areas.
• Communicate test status and milestones to department and project management.

Senior Business Systems Analyst

• Initiates and responds professionally to a high volume of calls in a timely and efficient manner, following standard operating procedures.
• Accurately establish and maintain member medication profiles for review by a Coordinator or Pharmacist.
• Collaborate with pharmacy peers, external and internal stakeholders on communication needs and best practices.
• Consistently produce quality of work that is above the industry average and meet service level expectations.

Pharmacy Program Specialist

• Oversees enrollment and billing operations across Medicare Advantage, Medicare Supplement, CHIP, and ACA products, ensuring accurate eligibility, premium billing, member maintenance, and ongoing operational performance.
• Leads Medicare Advantage appeals and grievances, ensuring timely, compliant resolution of member and provider appeals and grievances in accordance with CMS requirements.
• Ensures compliance with federal and state regulations, including CMS and applicable program requirements, through effective oversight of policies, procedures, controls, and regulatory reporting.
• Directs reconciliation, quality, and performance monitoring activities related to enrollment, billing, and Medicare Advantage appeals, identifying trends, risks, and opportunities for improvement.
• Leads audit readiness and regulatory support efforts, including responses to CMS audits, compliance reviews, and internal oversight activities related to enrollment, billing, and Medicare Advantage appeals and grievances.
• Partners cross‑functionally with Compliance, Claims, Customer Service, Sales, Product, Finance, IT, and other stakeholders to resolve complex operational issues and ensure enterprise alignment.
• Drives process improvement initiatives to enhance accuracy, efficiency, member experience, and regulatory outcomes across all assigned functions.

Manager, Government Enrollment & Appeals

Data Scientist

• Powering all HEDIS improvement initiatives through advanced data analytics and insight generation.
• Lead the development of predictive models to identify members at risk of care gaps and prioritize outreach opportunities.
• Translate complex analytical findings into clear, actionable recommendations for executive and operational stakeholders.
• Conduct pre/post and longitudinal analyses to evaluate program impact.
• Collaborate with Clinical, Quality, Provider Engagement, and Operations teams to align analytics with business needs.