Capital Blue Cross

Risk

• Actively monitor performance, productivity, and staff development activities.
• Lead and oversight Risk Adjustment functional areas driving optimal outcomes: Chart Retrieval, Coding (including Coding Quality/HCC Compliance), Analytics/Reporting, and Encounter Data Submissions serving Retrospective and Prospective Programs.
• Guide and oversees the creation, implementation, and monitoring process of the Risk Adjustment Program strategy, objectives, tactics, and initiatives to drive a year over year quality of care improvements, appropriate reimbursement, and compliance with CMS mandates, regulations, and audits.
• Lead oversight of Risk Adjustment vendors.
• Lead in the identification, evaluation, and management of risk adjustment vendors. RFPs readiness, potential vendors evaluation, selection, project implementation, etc.
• Implement a governance structure that provides significant oversight and audit readiness.
• Collaborate with the Government Program Compliance Officer to develop, execute and continually refine a quality assurance program to monitor, audit and improve the CBC Risk Adjustment Program.
• Develop and implement remediation strategies as needed with individual providers, provider groups, internal teams, etc.
• Support and guide business decisions, inform financial plans/forecast, bids development, risk adjustment activities and revenue optimization strategies.

Director, Risk Adjustment Program

Medical Director

• Lead clinical oversight for key MA partnerships across both internal functions such as network provider operations and external strategic partnerships with both digital and traditional clinical programs.
• Partner across Population Health, Government Programs and Provider Network leaders to evaluate the efficacy of existing clinical programs, and design clinical and operational strategies to optimize performance.
• Physician lead for quality management functions and market-facing representation to the provider network.
• Engage value-based care partners to enhance performance outcomes; leading, designing and driving scalable practice & provider engagement for MA STARS, TCOC & Risk programs.
• Thought leader influencing Medicare TCOC and affordability strategies, including utilization management (UM) trend control and UM process improvement initiatives.
• Assist in review and implementation of UM and medical policy, including recommendations for improvements to enhance efficiency, quality and effectiveness.
• Integrate pharmacy and medical care strategies, acting as a bridge partner with Capital’s pharmacy benefits manager and serving as internal subject matter expert on MA formulary design.
• Leverage existing analytics tools and assist in enhancing data products as critical infrastructure to design new clinical strategies and manage the performance of existing clinical programs.
• Work in collaboration with UM and Care Management (CM) to understand utilization trends and develop programs to address inappropriate utilization, readmissions and achieve MLR targets.
• Chairs high-cost claimant rounds across all LOBs.
• Clinical committee oversight including functions such as member safety, credentialing, Medicare appeals review and strategic partner Joint Operating Committees.
• Data-driven leadership aligns CMS compliant MA strategies to mitigate regulatory compliance risk while tracking and driving progress towards Capital’s annual goals.
• Renders medical management decisions that are member-centered, quality-first and holistically address clinical, psycho-social member needs.
• Leads a culture of evidence-based clinical decisions through sponsorship of population health care management rounds and member case reviews.
• Documents in medical management systems to memorialize clinical review, plan of care and coverage decisions.
• Works with network provider partners to access and use electronic health records, periodically supporting chart reviews for MA risk strategies.
• Support Chief Medical Officer, Vice President of Population Health and Government Programs stakeholders with other duties as assigned.

Medical Director – Population Health

Financial Planning and Analysis

• Deliver leadership to a team of three to five audit professionals
• Manage and oversee the company’s Model Audit Rule (MAR) assessment program
• Effectively plan and manage multiple, concurrent financial and operational audit projects
• Manage Internal Audit activities relative to work conducted by external auditors
• Complete special projects assigned by the Director, Internal Audit
• Serve as direct line manager for multiple professional audit staff

Manager, Financial and Operational Audit

Manager

• Lead strategic provider partnerships
• Negotiate mutually beneficial contracts
• Execute contract negotiations and drive provider network strategy
• Implement innovative reimbursement models
• Collaborate across internal teams and represent the contracting unit

Provider Contract Manager

Communications

• Lead the planning, development, and execution of strategic communication initiatives
• Produce clear, consistent, and on-brand content across multiple channels
• Collaborate with colleagues at varying levels in Marketing and external vendors
• Support seamless, timely implementation of corporate projects, programs, and products
• Create or maintain clear, consistent, and on-brand communications

Communications Specialist

• Overseeing the design, planning, implementation, and management of Capital’s voice infrastructure and associated communications facilities
• Leading strategic planning for voice services
• Managing vendor relationships
• Optimizing resources
• Collaborating with IT and business stakeholders to deliver scalable, cost-effective voice solutions

Manager, Voice Services

Actuary

• 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 translate classroom learning into fresh perspectives.
• Formally present the outcomes of their experience to the executive and extended leadership team.
• Receive periodic feedback and professional development programming.

Actuarial Intern

Network Operations

• Interns will have the opportunity to participate in a variety of experiences through meaningful work assignments, observation opportunities, and social interactions.
• Interns will have the opportunity to complete a service project with one of our community partners.
• Interns will participate in ongoing company initiatives and be challenged to translate their classroom learning into fresh perspectives that positively impact our colleagues, members, and the communities we serve.
• Interns will have the opportunity to formally present the outcomes of their experience and share their unique perspective to our executive and extended leadership team.
• A variety of Capital team members will provide interns with periodic feedback and professional development programming.
• The internship program strives to provide interns with formal and informal opportunities for the interns to network with Capital Blue Cross staff and participate in company-wide learning events.

Network Operations Intern

Consultant

• Responsible for project management, vendor oversight/program management and staff development activities as related to activities carried out by Health Education and Wellness
• Assists in the identification and analysis of population needs and proposes and develops targeted disease management, maternity management, and health education and wellness programs and services
• Data collection, reporting, and analysis of existing programs, services, and projects
• Business owner for direct vendor oversight for vendor relations during identification, selection, contract development, implementation, and post-implementation of effective disease, maternity and/or health education programs/services
• Support curriculum and staff development activities as primary preceptor for orientation and mentoring of staff
• Research, construct, and support delivery of educational activities to develop a high performance staff compliment