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.

Manager, Case Management

AI/Data Scientist

Customer Service Representative

Accounts Payable Specialist