E-Verify Program

Manager

• Serve as a team member on a multidisciplinary team, coordinating care, resources and/or services for members to achieve optimal clinical and resource outcomes.
• Utilize applicable clinical skillset and perform comprehensive assessments to determine how to best collaborate with members, family, internal partners and external services/providers on plans for treatment, appropriate intervention and/or discharge planning.
• Develop a member-centric plan tailored to members’ needs, health status, educational status and level of support needs; identify barriers to meeting goals or plan of care
• Utilize community resources and funding sources as needed in the development of the plan of care.
• Perform ongoing monitoring and management of member which may include scheduled follow-up with member, discussion of plan with member, appropriate services/education to address needs, appropriate referrals with supporting documentation, assessment of progress towards goals, modification of plan/goals as needed, with contact frequency appropriate to member acuity.
• Evaluate and facilitate care provided to members through the continuum of care (physician office, hospital, rehabilitation unit, skilled nursing facility, home care, etc).
• Educate members and encourage pro-active intervention to limit expense and encourage positive outcomes
• Effectively document all aspects of the plan from the initial assessment, development of the plan, implementation, monitoring, and evaluating outcome.
• May outreach directly to members identified as high risk, high cost, or high utilization cases.
• May review alternative treatment plans for case management candidates and assess available benefits and the need for benefits exception or flex benefit options, where eligible.
• May evaluate medical necessity and appropriateness of services as defined by department.
• As needed, develop relevant policies/procedures, education or training for use both internally and externally.

Case Manager

Director

• Direct, manage and lead efforts that define and enable strategic and operational priorities for the Pharmacy group.
• Lead staff responsible for accomplishing goals related to pharmacy operations, clinical and specialty pharmacy programs, opportunity analysis, solution design, provider/payer integration and vendor evaluation and management.
• Provides expertise and insights in drug coverage for provider administered therapy, pharmacy channel specialty drugs, and traditional retail medications.
• Champion innovation while identifying pharmacy-related opportunities and collaborations that drive value for Blue Cross NC members.
• Evaluate emerging pharmacy industry trends and the strategic needs of the department as it relates to overall business objectives.
• Oversee all clinical aspects of drug coverage from formulary management, policy development, and drug channel management.
• Develop new strategies to include total cost management, including real-world evidence for lowering total cost of care beyond drug expenditure to patient outcomes.
• Develop, in partnership with analytics teams, infrastructure to track drug trends and dissect changes in unit cost, utilization, and drug mix to support new ideation in management.
• Participate in the development of departmental strategic plans and objectives to improve achieve medical expense goals while maintaining standards in clinical excellence.
• Understand the evolving medication therapy space and develop strategies around traditional, specialty and gene therapies.
• Direct the management of formulary and medication policy development and maintenance for the purpose clinical quality and affordability.
• Oversee day-to-day operations related to tracking and managing drug expenditure in collaboration with medical economics teams in order to manage emerging trends in cost and clinical quality.
• Direct, manage, and/or support implementation of corporate projects that requires input on drug utilization, unit costs, and pricing dynamics in the pharmaceutical supply chain.

Director, Commercial Formulary and Medication Policy

IT Support

• Oversee architecture as a centralized, strategic function, ensuring technology selection, integration, and innovation across the enterprise.
• Define and deliver enterprise technology and architecture strategies that enable business growth, innovation, and healthcare digital transformation.
• Establish and enforce architecture standards, principles, and reference architectures to ensure consistency, security, and scalability.
• Provide strategic guidance on key technology decisions, from solution architecture to enterprise platforms.
• Lead enterprise integration and modernization efforts, including APIs, data interoperability, clinical data exchange, and cloud transformation.
• Monitor industry trends and emerging technologies to drive innovation and business value.
• Partner with business and IT leaders to align architecture with strategic objectives.
• Embed security, compliance, and risk management into all architecture decisions.
• Guide cost-effective architectural decisions that maximize platform reuse and optimize total cost of ownership.
• Provide oversight and guidance to solution architects to ensure scalable, secure, and resilient designs.
• Lead and develop a high-performing architecture team through clear goals, mentorship, and continuous learning.
• Define and track architecture KPIs to measure impact and value.

Director, Enterprise Architecture

Consultant

• Responsible for delivering consistent, profitable Blue Cross NC National Group sales
• Promoting current group retention and sale of new product lines to existing clients
• Building trusted, enduring relationships with complex clients and consultants
• Drives higher financial value for current clients by providing market-leading, data backed solutions
• Negotiate renewals and cross sell opportunities with high profile, complex clients and consultants
• Identify additional growth opportunities in ancillary products based on client’s needs
• Analyze client financial and utilization data and industry trends
• Develop a trusted advisor relationship with producers
• Collaborate with Client Services team to ensure group issues are addressed effectively
• Promote goodwill between BCBSNC and the community

Strategic Client Consultant I – National Accounts

Client Services Representative

• Synthesize go-to-market strategy and apply client-specific lens, advising sales teams on relevant trends, research, and product readiness.
• Provides recommendations to clients utilizing available metrics, client feedback, and knowledge of best practices.
• Recommend strategy-supporting products, programs and services.
• Create lasting client value by owning and executing key delivery activities, ensuring client-specific sold offerings operate in frictionless fashion.
• Support key sales activities through tailoring of messaging, content, and offering configuration.
• Collaborate with the sales team to provide a high level of value and customer satisfaction.
• Execute activities remotely as well as face to face with the client to ensure seamless post-sale delivery of sold products and offerings.
• Maintain strong product and offering knowledge, including product roadmap and testing timeline
• Attend client meetings and events and leverage knowledge of products, programs, services and value story of the enterprise in support of segment specific business goals and objectives.

Senior Client Service Advisor – Student Blue

• Perform clinical reviews to assess, facilitate, and coordinate the delivery of health care services
• Effectively coordinate with providers, members, and internal staff
• Review and evaluate cases for medical necessity against medical policy, benefits and/or care guidelines and regulations
• Provide notifications to member and/or provider, according to regulatory requirements
• Assess appropriateness for secondary case review by the Medical Director (MD) for denials

Episodic Care Manager – Behavioral Health, Autism Services

Business Operations

• Provide comprehensive business operations, reporting, planning, and vendor-relationship support across the segment/division.
• Support development of strategic goals and annual operating plans.
• Manage special projects assigned by leadership, including cost-reduction analyses or efficiency assessments.
• Consolidate and standardize analytical reporting across the business.
• Complete Monthly Premium Reporting, including premium loading and reconciliation.
• Serve as first-level service support for Mosaic partners, ACS, Dental, and Vision.
• Join leadership in internal and external partner meetings; document discussion points and drive follow-up.

Business Operations Associate

• Supports Sales, Account Management, and Leadership by managing new business, renewals, reporting, RFPs, and issue resolution.
• Enhances sales capacity, improves data accuracy, and strengthens collaboration across Dental, Vision, and Ancillary lines of business.
• Acts as a liaison among Sales, Underwriting, Medical Support, Marketing, and Operations.
• Ensures accurate, timely, and compliant execution of activities that drive growth and retention.
• Assists with large and complex RFP requests, including monitoring, tracking, and managing related reporting.
• Partners with medical internal teams to obtain product/client specific disruption, carryover, geo-access, and other required reporting.
• Manages high-level escalated issues related to benefits, products, and claims—ensuring timely resolution and communication.
• Works with Healthcare and National Accounts teams to secure quarterly reporting for group reviews.

Senior Client Service Advisor

Financial Planning and Analysis

• Lead the development, refinement and monitoring of strategic plans within the Health Plan
• Provide consultation and resources to shape and impact the planning process
• Ensure planning activities across the Health Plan are structured, transparent, and aligned to enterprise strategy
• Track, analyze, tools, and communicate planning efforts for the enterprise strategy
• Partner with business and financial planning resources for strong alignment
• Translate Health Plan Strategy into action planning assumptions, priorities, and execution roadmaps
• Consult with Strategy leadership on Strategic Planning efforts
• Encourage professional development within the Strategic Planning team
• Develop and maintain planning resources that support the cascade of strategic direction
• Collaborate with Shared Services and Enterprise Strategy to ensure planning consistency
• Act as a proactive planning resource to identify opportunities, risks, and trade-offs

Manager, Strategic Planning, Health Plan Strategy

Administrative Assistant

• Oversee Leader’s workflow including mail, calendar, correspondence, and telephone calls.
• Support Leader and other staff by scheduling, planning, and attending meetings as necessary.
• Provide support to include expense reporting and travel planning.
• May act as coordinator of departmental projects.
• Exercise considerable discretion and independent judgment.

Senior Administrative Assistant, Specialist

Full-stack Engineer

• Participate in technical planning & requirements gathering phases including Design, code, test, troubleshoot, and document software applications
• Ensure that technical software development process is followed on the project according to internal and industry best practices for software development and operational support
• Document and present design documents for project approval
• Develop and perform unit and integration testing and document results
• Perform peer code reviews
• Define measures and KPI’s
• Utilize key components of Aireon’s cloud ecosystem for the integrated products we launch and operate
• Perform analysis and troubleshooting of processing errors and data inconsistencies and provide solutions
• Software Development Life Cycle (SDLC)
• Understand Data Flows and Common Data Model
• Participate in daily scrum meetings and weekly status meetings to provide a status report of work in progress or accomplished, as well as issues encountered
• Track and maintain task activities using Azure DevOps tool
• Support implementation of CI/CD pipelines and test automation, as well as automate operational procedures (DevOps)
• Support creation of environments, set up cloud and on-prem infrastructure, and perform integration during product integration, deployments, and system testing
• Help troubleshoot and monitor production systems, and help fix performance issues and/or bottlenecks
• Create and maintain technical documentation following Aireon’s policies and procedures for software engineering
• Adapt and work with team members of various experience levels and locations

Software Engineer

Data Scientist

• Investigating events related to system performance or system outages
• Supporting development of ML models to extract insights from the data or forecast events and trends
• Assisting in data visualization to support requests from other departments
• Developing tools to process and analyze data
• Assist in algorithm development to support system enhancements

Data Science Intern

• Responsible for financial claims expense invoicing, reporting, analysis and forecasting
• Develop, analyze, interpret, report, and present historical and/or forecasted financial claims expense and stop loss coverage information
• Prepare claims expense financials, estimated claim expense and financial forecasts
• Prepare financial and business-related analysis and research
• Coordinate and direct the preparation of stop loss coverage for employer groups or stop loss vendors

Client Financial Analyst

Program Manager

• Manage/ administer smaller programs or a phase of a larger program to ensure that prescribed activities are carried out in accordance with program objectives
• Assess needs and coordinate resources to enhance existing programs
• Monitor the progress of program components to ensure the overall goals, schedules, and benefits of the program will be met
• Document and present program results through operational reports, outcomes studies, presentations and publications
• Prepare program reports for superiors
• Recommend and/or implement program and process changes as needed to achieve program goals and objectives
• Serve as a liaison between teams to collect updates and integrate input effectively
• Track surface issues requiring escalation and ensure follow through on action items
• Assist with planning, process updates, and development of simple frameworks, templates, and documentation

Project/Program Manager

Analyst

• Identifies, analyzes, and determines medical necessity, pre-existing conditions, benefit eligibility and/or individual consideration reimbursement allowances for novel and complex medical management related claims
• Acts as a member advocate to promote and coordinate the delivery of quality, cost-effective healthcare services based on medical necessity and contractual benefits
• Ensures that review and determinations meet all requirements per line of business by Regulatory and Accrediting bodies
• Identifies, documents, and escalates system and process problems
• Through analysis, determines root cause and recommends possible solutions
• Reviews physician-submitted and member-submitted claims for specified services, utilizing professional knowledge and developed criteria
• Refers cases that do not meet criteria to the Medical Director with appropriate clinical analysis and summaries
• Issues denials according to department protocols
• Documents outcome of reviews
• Maintains confidentiality of all PHI in compliance with state and federal laws
• Recognizes, documents, and reports inappropriate billing patterns or utilization trends of professional and institutional providers to appropriate business owner
• Identifies situations in which claims filing/coding guidelines are not being followed by providers
• Communicates with members and providers to obtain additional information
• Informs members, providers, and internal customers of claims status and determinations
• Performs post adjudication review of claims related to coding, billing and reimbursement