Capital Blue Cross

Manager

• Provides clinical oversight and management of UM audit activities
• Leads and coordinates UM audit activities
• Audits UM activities to ensure compliance with established timeframes and standards of performance in accordance with the National Committee for Quality Assurance (NCQA), the Department of Health (DOH), Centers for Medicare and Medicaid Services (CMS), and other state and federal regulatory requirements
• Prepares and presents audit findings to UM leadership, corporate and Medicare compliance and/or the Quality and Accreditation team as appropriate
• Ensures sample size and frequency of audits is appropriate for the population
• Monitors vendor compliance activities
• Responsible for CMS reporting requirements including: Part C Organization Determinations, Appeals, and Grievances (ODAG) report review and auditing for Capital and delegated UM vendors

Manager, Utilization Management, Quality and Oversight

Data Analyst

• Support Capital Blue Cross Risk Adjustment Medicare submissions and day-to-day analytics activities that impact the Medicare submission process
• Assist and/or develop new reports or analysis, enhance key existent reports and/or analysis processes, and methodologies of the Risk Adjustment Program operations and initiatives
• Support the implementation and on-going activities of vendor operations and analytics tools
• Lead the error correction process to ensure maximum acceptance rates for encounter submissions
• Develop standardized reporting and controls for vendor’s management and performance monitoring process to ensure appropriate and timely data flow between teams
• Collaborate with Actuarial to monitor the impact of coding programs on revenue for forecasting and monthly financial statement accruals

Healthcare Encounter Submissions Data Analyst

• The Care Manager is responsible for the coordination of services for members who meet established criteria, with an emphasis on education/self-management and promoting quality care and cost-effective outcomes.
• The Care Manager uses a collaborative process to assess Member needs, review options for services and resources, develop and implement a plan of care, coordinate resources, monitor progress, evaluate Member status, discharge Members, and fully document the individualized member care management process and outcome.
• The Care Manager will address medical, psychosocial, clinical needs, and behavioral health needs including members with mental health and substance use disorder needs.
• Care Managers provide counseling and referrals to community/local/state programs; collaborate with caregivers, providers, community agencies, behavioral health, and other resources to coordinate care to achieve member’s optimal health status.
• The Care Manager is responsible for the management and oversight of a caseload of moderate - high risk Members with complex medical/behavioral /psychosocial needs.

RN Care Manager – Maternity

Human Resources

• Develop and maintain influential relationships with leadership to drive talent outcomes that support business objectives.
• Assess organizational performance systemically and define talent gaps.
• Provide proactive HR support, managing all aspects of the employee lifecycle.
• Partner with business leaders and Finance on regular workforce planning data management.
• Serve as a resource and advise on general policy application and process/practice implementation.
• Conduct stay interviews and exit interviews to identify trends and issues.
• Facilitate annual talent and succession planning events.

Senior HR Business Partner

Analyst

• Perform contract administration activities encompassing preparation of contract settlements to ensure that claims are ultimately paid in accordance with the provisions of the contracts
• Perform research, analytic and reporting work in support of the Provider Contracting and Value Based Programs ACA agreements, provider reimbursement strategies and new contracting initiatives
• Work with team manager and other analysts to develop and administer contracts between Capital BlueCross and various providers
• Assist in developing an annual plan for the team which considers available resources and anticipated workload
• Responsible for the analytical functions necessary to effectively administer provider contracts
• Prepare provider contract settlements ensuring accuracy
• Manage the Cost Rate Adjustment process
• Respond to questions and concerns raised by providers
• Participate in drafting contracts for new and existing providers
• Develop proactive analytical studies to assess changes in provider billing patterns and charge description masters
• Perform audit functions on the work of others in the Provider Operations unit

Network Contract Analyst

Affiliate Manager

• Serve as the primary point of contact for the CIO, managing complex calendars, meetings, travel, external visitors, and executive logistics.
• Proactively manage meeting cadence and priorities to ensure time is focused on the highest-impact technology and business initiatives.
• Prepare agendas, briefing materials, and pre-reads for ELT, Board, and technology leadership meetings.
• Attend select leadership, operating, and governance meetings as a partner to document minutes, decisions, and action items.
• Ensure participants are prepared in advance and accountable for follow-ups and commitments.
• Anticipate needs and ensure the CIO is fully prepared for meetings, presentations, and enterprise communications.
• Handle sensitive and confidential information with the highest level of discretion.
• Manage budget tracking and oversee contracts and vendor engagements as delegated by the CIO.
• Partner with the CIO to track strategic priorities across IT, Digital, Data, Security, and transformation initiatives.
• Maintain dashboards, trackers, and action logs for key initiatives, risks, and dependencies.
• Drive follow-up with leaders and teams to ensure commitments are met without requiring the CIO to chase updates.
• Support preparation of executive-level materials including Board updates, leadership presentations, operating reviews, and strategic readouts.
• Act as project manager for CIO-sponsored initiatives and special projects.
• Coordinate timelines, stakeholders, dependencies, and deliverables across technology and business teams.
• Build strong relationships across IT and business functions to facilitate communication and alignment.

Executive Programs Partner – Assistant

• Responsible for day-to-day coordination, leadership, and strategy of the Pharmacy Member Outreach arm of the Medicare Pharmacy team
• Oversee the PBM Care Team performance
• Prioritize daily, weekly, monthly focus of PBM Care Teams and Member Outreach team
• Clear oversight and formal assessment of PBM Care Team performance
• Manage personnel issues, including hiring, training, staff performance reviews, and facilitating staff development activities.