Premera Blue Cross

Manager

• Participate in development of Clinical Programs’ strategy and planning in accordance with company's mission and strategic goals, federal and state law and regulations, and accreditation standards.
• Assist in the selection, training, evaluation, and development of professional paraprofessional, and administrative team members.
• Lead Care Management teams in effective performance of job functions, which may include preauthorization, outpatient and inpatient management, case management, retrospective claim review, and delegated management oversight.
• Participate in the development and monitoring of budgets in accordance with department and organizational objectives.
• Assist with the adjustment and direction of work processes to support cost and utilization variations.
• Participate in the development, implementation, and monitoring of the department's performance standards, utilizing quality improvement methodologies to refine procedures.
• Participate in the establishment and implementation of Care Management policies as required.
• Foster collaborative work environment that encourages team building, facilitates cohesive synergetic performance of Care Management functions, while valuing the individual diversity and uniqueness of all employees.
• Build and maintain cooperative business relationships.
• Participate in Total Quality Management activities and processes to assure operational compliance with regulatory requirements, including NCQA, NEMIS, HCFA, and OIC.
• Ensure team members that can articulate the expectations of performances are invested in productivity and customer service, and can describe a positive feeling about the work environment.
• Effectively manages deficits with improvement plans and consistent follow-up.

Manager, Case Management

Data Scientist

• Develop and tune generative/agentic AI solutions aimed to solve highly complex problems within the delivery of healthcare or health plan services.
• Establish comprehensive tracking of experiments to manage the iterative process of building and testing models ensuring that AI solutions fulfill business requirements.
• Provide statistical rigor to these evaluations via the design of controlled tests to measure the impact of changes to the solution.
• Form and leverage strong collaborations with AI engineers to scale solutions for production grade performance.
• Develop and implement complex agentic workflows that utilize AI agents for autonomous task execution, enhancing operational efficiency and decision-making capabilities.
• Solve new business problems by reaching, designing, building, and validating complex or novel machine learning models.
• Conduct feature engineering and model optimization.
• Manage the complete lifecycle of machine learning models from conception to deployment while following SDLC and responsible AI practices.
• Consult with senior and executive level business leaders to scope, model, and recommend AI/ML, technical, or analytic solutions to highly complex problems within healthcare.
• Build and ensure consensus with stakeholders regarding the feasibility, tradeoffs, and delivery of recommended solutions.
• Research, recommend, and apply causal techniques (RCT, DiD, PSM, causal graph models, counterfactual reasoning, etc.) to estimate treatment effects to quantify or validate business benefit of complex health plan activities.
• Explain business impact to program owners and leadership using approaches that are meaningful to those audiences.
• Partner with program owner in the promotion or publications of results when applicable.
• Participate in code peer reviews and quality assurance testing.
• Troubleshoot issues as they arise to solve problems independently and collaboratively.
• Serve as the technical subject matter expert to establish best practices for the team and help coach the team via formal and informal initiatives.
• Maintain regular contact with customers through development cycle to ensure each step of implementation tracks customer’s needs.
• Lead analytics projects applying a working knowledge of Agile and SCRUM project methodologies.

AI/Data Scientist

Customer Support

• Accountable for inbound and/or outbound phone-based customer service; provides first call and/or email resolution.
• De-escalates calls and provides caller education.
• Follow-up, resolve, and document issues in a timely manner.
• Route inquiries needing further investigation to the appropriate department.
• Conduct routine research as needed.
• Work with highly sensitive information while maintaining Personal Protected Information (PPI) requirements.

Customer Service Representative

Accounts Payable

• Enter and validate invoices in ERP system. This includes managing the invoice send back process and resolving invoice discrepancies.
• Ensure adherence to vendor payment terms and company policy.
• Maintain accurate vendor master data and documentation.
• Review vendor statements and work with the business and suppliers to resolve outstanding issues.
• Manage team mailboxes daily and ensure email responses are completed within 48 hours.
• Update and maintain documentation of processes and procedures.
• Ensure compliance with policies, internal controls and governance standards.
• Support audits and provide required documentation.
• Build and maintain strong internal and external relationships.
• Support SLA adherence and straight-through invoice processing.
• Work collaboratively with employees at all levels to detect issues and implement agreed upon solutions relating to system and transaction discrepancies.
• Utilize accounts payable best practices to design, develop and implement processes, procedures and training.
• Analyze new laws, proposed laws and regulations that govern accounts payable and related processes and implement process changes to improve efficiency.

Accounts Payable Specialist

Medical Reviewer

• Conduct detailed clinical and coding evaluations to ensure claim payments are accurate.
• Review medical records and appeal submissions to assess coding accuracy.
• Serve as a subject matter expert for claim payment accuracy including pre-payment claim editing and auditing.
• Coordinate with vendors and internal teams to design and implement payment integrity solutions.
• Collect, analyze, synthesize, and interpret multiple sources of data.
• Lead technology/tool updates, testing, and troubleshooting with IT teams and vendors.
• Respond to payment integrity inquiries from providers, internal teams, and vendors.
• Manage multiple projects or audits with minimal supervision.
• Collaborate with appropriate departments regarding payment integrity issues identified during auditing processes.
• Develop and facilitate presentations by analyzing and interpreting data to communicate business issues and findings.

Clinical Review Specialist

Consultant

• Act as an internal consultant providing guidance on complex analytical projects and planning resources in order to meet project deadlines.
• Analyze and develop business requirements to recommend scalable, cost-effective solutions.
• Partner with stakeholders across all levels to define and implement strategic initiatives.
• Identify opportunities for automation and AI-driven process improvements, assessing feasibility and business impact.
• Interface with management at all levels of the company to ensure quality and timeliness of projects.
• Design, build, and deliver automation workflows and AI-enabled solutions, ensuring adoption and measurable outcomes.
• Lead projects from planning through execution, ensuring delivery on-time, on-budget, and on-value.
• Manage project risks, track progress, and report on achievement of objectives.
• Collaborate with leadership to align solutions with corporate strategy.
• Develop and utilize data gathering tools; Prepare reports synthesizing analytical results and outlining business cases.
• Prepare, evaluate and distill analysis conducted by other departments and/or outside consultants.
• Other duties as assigned.

Internal Consultant IV

Analyst

• Collaborate with company management to identify key business issues, outline strategic alternatives and recommend action plans to senior management.
• Develop analytical tools and models to support strategic business planning.
• Consult with customers on complex projects and identify financial impacts.
• Participate in strategic business planning and provide forecasting and analysis expertise.
• Measure and report on accuracy rates by month.
• Estimate the impact of future activity (system changes, process changes, training classes, communications, etc.) on contact handle time and volume projections.
• Examine historical data to recommend skill and staffing patterns based on daily statistics for hiring and training class assignments.
• Research, compile and maintain historical data required for management records and extensive analysis.
• Generate ad hoc reports to include trend analysis as requested by operations management.
• Provide budgeting figures to project skill and staffing needs in monthly and annual timeframes.
• Load and maintain corporate budget tool.
• Other duties as assigned.

Forecasting Analyst

• Manage assigned team including hiring, coaching/mentoring, supporting professional development, and providing appropriate and timely performance feedback to staff, both informally and during formal review processes.
• Identify, design, and implement appropriate solutions to staffing and succession planning, quality and workload problems in a timely and effective manner.
• Responsible for the day-to-day operation and strategic planning to consistently achieve monthly and annual performance measures.
• Anticipate the impact of the changing business environment on assigned work areas and adjust work assignments and processes as necessary.
• Use monthly forecasting and planning for multiple areas of responsibility.
• Decisions are made with a high level of independence.
• Manage assigned projects, meeting deadlines and assuring results meet the business needs of the organization.
• Responsible for resolving more difficult internal and client issues as they arise.
• Recommend budget requirements for assigned areas using forecasting and planning tools.
• Manage within approved budgets and requests exceptions as needed.
• Build effective working relationships with employees at multiple layers across the organization gaining insight into business requirements and influencing diverse and sometimes competing agendas to gain alignment.
• Design, implement and monitor procedures to ensure smooth, accurate and timely work flow within assigned groups and works collaboratively with others throughout Premera to implement cross-team and company-wide procedures and systems changes.
• Identify, design, and implement appropriate solutions to staffing, quality and work load problems in a timely and effective manner.
• Establish, monitor, and remediate when needed, performance metrics, including customer facing escalations and standards, and performance guarantees for specific lines of business or scorecard performance. This may require cross departmental collaboration.
• Develop strategic partnerships to ensure vendors are engaged with the business and contracts are managed ensuring service level agreements are achieved. This position may be the primary contact for government agencies, employer/group, and/or consultant.

Individual Market Customer Service Manager

Learning and Development

• Conduct successful classes (in-person and virtual) on assigned Premera operational systems.
• Use effective training techniques and methods based on adult learning principles.
• Collaborate effectively with peers to ensure successful class delivery.
• Foster strong working relationships with Team Leaders and Technical Support Staff.
• Maintain proficiency levels on technical platforms and all lines of business through continuous learning.
• Effectively communicate with business partners and leaders throughout the training delivery process, including expectation meetings, daily status reports, and post-graduation debriefing.
• Lead the classroom experience by monitoring attendance, testing productivity and accuracy levels, addressing individual or team behavioral issues, and providing accurate feedback to trainees.

Training Specialist

Data Engineer

• Design, build, and optimize data pipelines and infrastructure to support AI/ML models and advanced analytics.
• Build and maintain robust ETL/ELT pipelines for structured and unstructured data.
• Design and implement scalable data architectures for AI/ML workloads using cloud platforms (AWS, Azure, GCP).
• Collaborate with data scientists to prepare and transform data for model training and inference.
• Integrate ML models into production systems, ensuring efficient data flow and monitoring.
• Optimize data storage, retrieval, and processing for large-scale datasets.
• Implement data quality checks, compliance standards, and security best practices.

Data Engineer II

• Engage target members (those who are facing medical, mental health and/or substance utilization disorders) and build a relationship that will support open and constructive dialog on sensitive topics.
• Conduct initial holistic health assessments that help build an understanding of a member’s specific situation and needs and identify any social determinants of health (SDOH) and cultural influences that may impact potential lifestyle changes.
• Create a space where a case manager and member can collaborate, along with relevant caregivers and providers, to develop a member-centric case management plan that sets goals, addresses potential barriers, and leads to improved health outcomes.
• Monitor, evaluate, and update the effectiveness of the member's case management plan to ensure progress toward goals is being made and that current goals remain pertinent.
• Facilitate communication and coordination among the health care team to maximize delivery of appropriate care.
• Provide interventions focused on removing barriers, promoting positive behavior change using motivational interviewing techniques, and stabilizing the members’ natural support systems by ensuring that caregiver needs are identified and being met.
• Maintain concise, accurate, and timely documentation that meets accreditation, contractual, and legal requirements.