E-Verify Program

Collections

• Initiating calls with patients to collect payments and settle accounts
• Following up on accounts, receiving and processing payments, updating incomplete and missing account information
• Collaborating with patients to create payment arrangements and counsel them on financial assistance programs
• Coordinating payment resolution on unpaid accounts
• Contacting patients to discuss and resolve outstanding balances
• Obtaining and processing payments
• Verifying payments and adjustments have been received and posted
• Maintaining and supporting customer accounts and inquiries
• Receiving and resolving calls from patients, insurance companies, attorneys, and departments
• Ensuring correct billing by addressing accounts with incomplete or missing information

Collections Representative

Manager

• Perform clinical reviews to assess, facilitate, and coordinate the delivery of health care services
• Review and evaluate cases for medical necessity against medical policy, benefits and/or care guidelines and regulations
• Communicate and collaborate effectively with internal and external clinical/non-clinical staff
• Appropriately and fully document outcome of reviews and demonstrate the ability to interpret and analyze clinical information

Episodic Care Manager

Business Intelligence Developer

• Collaborate with business areas to conduct interactive and iterative user design sessions to produce rapid solution prototypes
• Collaborate with Data Engineers and Data Scientists to identify, create and influence optimal solution design to deliver actionable insight
• Mentor and provide knowledge transfer to junior team members by guiding them on development best practices
• Design and architect high performance data visualization solutions for large-scope projects to enable delivery analytic value and ensure they are maintainable and scalable as business needs dictate
• Facilitate cross-functional problem solving sessions to arrive at optimal solutions accounting for stakeholder needs to ensure successful project delivery.
• Provide team status in various projects, escalate issues as needed, access and communicate risks to the development schedule and project to represent the Viz Team& interests in cross-functional project teams and ensure project success.
• Create, maintain, and enforce data visualization governance and development standards to continuously and proactively improve the quality of solution development and efficiency of processes across the enterprise.

Senior Clinical BI Analyst

Risk

• Lead a team to establish governance and oversight across Health Plan priorities
• Collaborate with Health Plan business units and planning teams
• Manage performance of the Health Plan’s 3-5 year strategic plan across all segments
• Act as the governing body for the Health Plan to monitor performance
• Oversee performance across all Health Plan metrics
• Provide support to the Health Plan planning team
• Develop performance management processes and protocols

Director, Health Plan Strategic Plan Governance – Performance Execution

Human Resources

• Determine and recommend employee relations practices necessary to establish a positive employer-employee relationship and promote a high level of employee engagement.
• Act as an independent, confidential resource providing clients with analysis of facts, conclusions, and recommendations in response to internal and external employee concerns.
• Provide guidance, consultation and coaching to management and HR Business Partners on sensitive work-related issues including conflict resolution, performance management, interpretation of company policy, culture, and values.
• Work closely with the People Strategic Advising team to deliver recommendation that may include coaching, training, and/or corrective action.
• Maintain a strategic partnership with Compliance, Legal, People Strategies and management to ensure alignment with Blue Cross NC’s culture.
• Will navigate a number of different technologies and a significant amount of documentation for record keeping.
• Maintain a strict standard of confidentiality and empathetic approach in handling company sensitive information, reports, and correspondence.
• Focus on Blue Cross NC’s efforts to expand beyond the borders of North Carolina by reviewing legislature, notifying departments of any statutory changes to federal or state labor and/or employment laws, and ensuring company-wide compliance.
• Partner with the Ethics team in conducting internal workplace investigations.

Principal Employee Relations Advisor

Business Analyst

• Responsible for facilitating and performing complex research and analysis to support business operations.
• Discerns business needs, elicits, documents, and manages requirements, and develops business and functional requirements to solve larger and/or more complex business problems through enabling technology and/or improved business processes.
• Work completed would be focused on broader business unit, process or other solution context (domain) but also involves working with technical partners to communicate business requirements.
• Elicit, analyze, document and manage requirements for changes to business processes, policies, information, and information systems for larger and/or more complex business problems.
• Develop and elicit requirements for departmental and corporate projects that are more complex in nature as requested by internal/external customers; prepare business and functional requirements.
• Communicate and validate requirements with stakeholders and identified SMEs.
• Ensure creation of and adherence to requirements approach and management plan in alignment with an overall project plan.
• Collaborate with project teams to adhere to solution scope and create and maintain requirements traceability.
• Drive and execute business readiness activities including the communication plan to support changes to technology, processes and people.
• Support training and conduct focused analysis to ensure efficiency of project implementations and ensure desired results.
• Develop new procedures, specifications for systems changes or other solution recommendations for more complex product and/or process changes.
• Work with cross functional management and staff to implement changes.
• Design and conduct post implementation audits and create customer feedback mechanisms to gather ongoing information about business processes.
• Analyze results and create plans to address weaknesses.
• Identify the business process and organizational impact of solutions; conduct analysis of workflow process and designs, test and implement solutions.
• Ensure managed requirements change request process and documentation throughout project lifecycle.
• Develop and maintain reporting tools for use in measuring business area performance against metrics/industry benchmarks and ensuring data integrity and systems stability in support of operations management.
• Provide timely and accurate access to data, distribute reports and present/explain results to business area supported as well as to other BCBSNC areas.
• Work with trainers to develop training programs that target problem areas.
• Use and promote industry standard analysis techniques, such a data flow modeling, use-case analysis, workflow analysis, business process mapping, functional decomposition analysis and/or financial ROI modeling for larger and more complex initiatives.
• Independently create effective presentations for review by varied levels of leadership; thoroughly document all analysis assumptions, procedures and results in a manner appropriate for both senior executive and management review.
• Proactively identify areas of potential business risk, on projects both within and outside of control, make recommendations related to mitigation and escalate as necessary.
• Build and support strong business vendor relationships by documenting business issues, determining project needs, and supporting training as needed.
• Provide oversight and regularly perform peer reviews for less experienced analysts.

Senior Business Analyst

Medical Billing and Coding

• Analyze necessary documentation, including medical records/charts, and apply clinical coding expertise to evaluate appropriateness of provider coding
• Develop and maintain professional working relationships with Medical Providers and their staff necessary to facilitate onsite review of medical records
• Maintain documents for tracking audit results, status of reviews etc.

Coding Specialist – Medicare

Full-stack Engineer

• Build a cohesive team and manage people effectively which includes managing individual performance and attendance (including vacation and sick time).
• Balance and plan the short-term actions of the team and be accountable for the overall safety of the service on a day-to-day basis throughout their period of duty.
• Monitor overall network health and performance.
• Think critically about systems and make adjustments/decisions consistently as needed.
• Manage and communicate service change and repairs to end users and stakeholders.
• Ensure detailed logging of operations reports pertaining to maintenance and ensure that Occurrence Reporting to Competent Authorities (i.e. EASA) is completed satisfactorily.
• Maintain a thorough understanding of all relevant industry standards and best practices for service management and maintain the appropriate certificate of competency associated with the role.
• Adhere to policies, procedures, and controls especially regarding safety and security considerations, customer service, incident and change management, and information protection.
• Collaborate closely with engineering, network operations, security operations, contractors, and system administrators, to ensure operational quality and integrity at all times, remotely supporting customer implementations and onboarding of new customers when required.
• Ensure that all processes used by the service desk are thoroughly documented, consistently audited, and regularly improved.

Service Desk Tech Lead

Actuary

• Accountable for completion of complex actuarial or analytical projects, ensuring timeliness, compliance, and quality of work.
• Provide proactive and strategic thought leadership of ways to improve processes, reduce risks, and meet department and enterprise objectives to achieve profitable growth and/or improve value, quality, and access for Blue Cross NC customers.
• Achieve segment financial targets and provide concise explanations of results and variances to expectations; act as a financial steward for the company.
• Communicate effectively with all levels and divisions within the organization, including Divisional Leadership.
• Manage external partnerships with vendors, auditors, regulators, and health care providers, including effective negotiation of contracts and/or rates.
• Develop and maintain strong business relationships with internal partners through business expertise and exceptional support; act as a strategic advisor.
• Meet continuing education standards required for job function, thought leadership and maintenance of actuarial credentials.

Consulting Actuary – Part D

• 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