Blue Cross & Blue Shield jobs - 18 jobs

Your Role The Sr. Director of Product Management for Core Health Plan is responsible for owning the strategy, outcomes, and technology enablement for core health plan offerings. This includes claims processing, network management, product benefit design, and eligibility and enrollment. The role ensures competitive, compliant, and customer-focused products that deliver measurable business results. This leader will own product outcomes end-to-end, working closely with internal teams, technology partners, and external stakeholders to define, deliver, and optimize solutions that meet market needs and regulatory requirements. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Shift: Mon.-Thurs. 12:15-8:30pm, Fri. 10:45a-7pm Bring your drive for excellence, team orientation and customer commitment to Independence Blue Cross; help us renew and reimagine our business and shape the future of health care. Our organization is looking to diversify, grow, innovate and serve, and we are looking for committed, empowered learning-oriented people to join our team. If this describes you, we want to speak with you. Job Summary: Behavioral Health Triage Case Manager position works with at- risk members to facilitate clinically appropriate linkages to care. Triage Case Managers collaborate on care plan development and coordination with members and members health care team including physicians by screening, assessing, planning, facilitating, monitoring and giving input when adjustment is needed, and advocating for the member on an individual basis. Case Managers use clinical and motivational interviewing skills to assess member's need including crisis intervention to navigate and connect members to timely and effective services. Triage Case Managers work with the member to identify and address barriers to member's adherence to standards of evidence -based medicine. The case manager facilitates communication between the patient, family, and members of the health care team while acting as an educator and link between the patient, providers and the plan, ensuring high quality, cost-effective services are delivered. Helps members coordinate care and navigate the healthcare system. Key Responsibilities: * Provides telephone triage, crisis intervention and care navigation for at-risk members with mental health and/or substance use concerns * Demonstrates the ability to engage with members, and families, effectively assessing needs; providing evidence informed information, resources, and navigation to promote accurate and timely access to appropriate behavioral health services * Skillfully deescalates callers, provides brief supportive counseling and takes action in crisis situations. Manages high risk interactions to ensure the appropriate level of support and intervention is provided in an efficient manner. * Matches members with appropriate behavioral health and substance use providers based on clinical assessment and access needs, follows processes to ensure members are connected to care * Proactively incorporates lifestyle improvement and prevention opportunities into member interactions and coaching. * Contacts members physician/health care provider when needed especially in more complex behavioral health situations requiring case management intervention to facilitate care coordination and potential care plan changes. * Identifies on-line, telephonic and community- based resources that can assist the member in achieving and maintaining their personal health goals. Assist the member in accessing those services. In addition, assist in maximizing the use of member's benefits and ensuring coordination of services and outcomes. Qualifications - Internal Qualifications: Education/Licensure: * Active PA Registered Nurse License required. B.S.N. or LSW, LCSW, LPC Experience, Knowledge, & Skills * Minimum of three to five years post licensure in behavioral health clinical experience in a hospital or other health care setting including training in crisis intervention and suicide prevention. * Previous experience preferred in Utilization Review or Case Management, Care Navigation * Knowledge of DSM 5 and ASAM * Ability to work independently using critical thinking to resolve complex behavioral, medical, and psychosocial issues for our members. * Ability to adapt clinical assessment skills to telephonic assessment and follow-up. * Comfortable with new ideas and methods; creates and acts on new opportunities; is flexible and adaptable. * Exceptional problem-solving and organizational skills required. * Works to build relationships and provides exceptional customer service. * Able to work effectively as part of a team. * Highly professional interpersonal skills. * Strong computer skills and experience with Microsoft Office Suite. Fully Remote: This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence's physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania. Independence Blue Cross is an Equal Opportunity and Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability. Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together, we will achieve our mission to enhance the health and well-being of the people and communities we serve. The Auditor, Payment Integrity role conducts pharmacy claim audits for Independence Blue Cross to ensure accurate provider payments, detect fraud, waste, or abuse, and improve audit processes. It requires a Certified Pharmacy Technician with at least four years of experience, including pharmacy and audit work, strong analytical skills, and proficiency in Microsoft Office and pharmacy claims systems. * Conduct audits of claims submitted to Independence Blue Cross (IBX) to ensure accuracy of provider payments and charges. * Analyze provider billing patterns to detect potential fraud, waste, or abuse. * Perform audits through daily reviews, live audits, and desk audits to identify inappropriate billing practices. * Review and verify provider billing records, collaborating with CFID audit analysts, auditors, investigators, internal, and external sectors * Execute standard provider audit assignments using sound audit methodologies to uncover patterns of abuse or fraud. * Screen and audit claim samples-both summary and detailed-to select cases for further review. * Initiate and validate claim adjustments, maintain comprehensive audit documentation, and prepare statistical reports. * Identify and escalate potential provider fraud or abuse to management. * Contribute to the development and implementation of new audit processes and functions. Qualifications * Certified Pharmacy Technician (CPhT) required. * Minimum of four (4) years of relevant experience, including: * At least two (2) years in retail or hospital pharmacy. * At least two (2) years in pharmacy audit. * Extensive understanding of healthcare provider audit practices and medical terminology. * Familiarity with fraud, waste, and abuse detection methodologies. * Strong written and verbal communication skills for reporting and presenting audit findings * Proficiency in Microsoft Office applications, including Excel, Word, Outlook, SharePoint, and Access. * Advanced Excel skills (pivot tables, VLOOKUP, data analysis). * Experience with pharmacy claims systems such as RxTrack and RxClaim is preferred but not required. Fully Remote: This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence's physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania. IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability. Must have an Android or iOS device that is compatible with the free Microsoft Authenticator app.

Your Role The Risk Adjustment Compliance team plays a critical role in ensuring that Blue Shield maintains appropriate adherence to federal and state regulations. The Director, Risk Adjustment Compliance will report to the Senior Director, Government Programs Compliance. In this role you will provide strategic leadership and management of the department overseeing compliance with regulations and laws related to Risk Adjustment across our Marketplace (ACA), Medicaid and Medicare lines of business, which includes implementation of elements of an effective compliance program. You will oversee the development of risk assessments oversight and the monitoring of work plans pertaining to Risk Adjustment and partner with business areas to ensure and implement effective prevention, detection and correction of compliance issues.

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our mission to enhance the health and well-being of the people and communities we serve. The Behavioral Health (BH) Autism Care Management Coordinator's primary responsibility is to evaluate a member's BH condition through the review of medical records (including medical history and treatment records) to determine the medical necessity for Autism and Applied Behavioral Analysis services based on advanced knowledge and independent analysis of those medical records and application of appropriate medical necessity criteria. If necessary, the BH Autism Care Management Coordinator directly interacts with providers to obtain additional BH information. The BH Autism Care Management Coordinator has the authority to commit the company financially by independently authorizing services determined to be medically necessary based on their personal review. For those cases that do not meet established criteria, the BH Autism Care Management Coordinator provides relevant information regarding members BH condition to the Medical Director for their further review and evaluation. The BH Autism Care Management Coordinator has the authority to approve but cannot deny the care for patients. The BH Autism Care Management Coordinator is also responsible for maintaining regulatory compliance with federal, state and accreditation regulations. Additionally, the BH Autism Care Management Coordinator acts as a patient advocate and a resource for members when accessing and navigating the behavioral health care system. Key Responsibilities * Applies critical thinking and judgement based on advanced knowledge of Applied Behavioral Analysis (ABA) and other treatments for Autism Spectrum Disorder (ASD) to cases utilizing specified resources and guidelines to make approval determinations Utilizes resources such as; InterQual, Care Management Policy, Medical Policy and Electronic Desk References to determine the medical appropriateness of the proposed plan. * Utilizes the behavioral health criteria of InterQual, and/or Medical Policy to establish the need for authorization, continued care, intensity/dosage of ABA services and, and ancillary services. InterQual - It is the policy of the Medical Affairs Utilization Management (UM) Department to use InterQual (IQ) criteria for the case review process when required. IQ criteria are objective clinical statements that assist in determining the medical appropriateness of a proposed intervention which is a combination of evidence-based standards of care, current practices, and consensus from licensed specialists and/or primary care physicians. IQ criteria are used as a screening tool to support a clinical rationale for decision making. * Contacts servicing providers regarding treatment plans/plan of care and clarifies medical need for services. * Reviews Autism diagnostic evaluations, and requests for Applied Behavioral Analysis (ABA)services with providers to ensure valid diagnoses, and medically necessary services. Collaborates with providers to obtain and clarify required information for review. * Provides education and resources to caregivers/families and providers regarding autism benefits, Applied Behavior Analysis (ABA) treatment, company policy and procedures. Supports education of caregivers /families and providers on diagnostic, assessment and authorization processes and required documentation to facilitate efficient diagnosis, access to care and utilization management processes. § Assists providers with shaping of ABA services to ensure progress, proposes modifications to align with medical necessity criteria and supports alternative care planning when requests for services do not meet medical necessity criteria. § Identifies physical and BH conditions, family and social needs, barriers to progress and facilitates coordination with IBX Care Navigators and Case Management services as well as service providers (such as medical, speech, occupational therapy, physical therapy, IEP services) for comprehensive care coordination and services. * Identifies and refers cases in which the plan of care/services are not meeting established criteria to the Medical Director for further evaluation and determination. * Performs early identification of members for discharge planning support to ensure appropriate transition to services including community based and other appropriate services. * Appropriately refers utilization, access issues, or trends to Autism Care Management leadership, Quality Management Department, Network staff to support continuous quality improvement activities. * Ensures requests are covered within the members' benefit plan. * Ensures utilization decisions are compliant with state, federal and accreditation regulations. * Meets or exceeds regulatory turnaround time and departmental productivity goals when processing referral/authorization requests. * Ensure that all key functions are documented in accordance with the Care Management Coordination Policy. * Maintains the integrity of the system information by timely, accurate data entry. * Performs additional duties assigned. Qualifications Education/License: * Active unrestricted independent clinical mental health license (LCSW, LSW, LMFT or LPC, Psychologist) * Board Certified Behavior Analyst Certification Experience * 3+ years post independent licensure with facility based and /or outpatient psychiatric and/or substance use disorder treatment. * 3+ years BCBA certification experience specifically providing ABA services including oversight of paraprofessionals performing ABA services. * Experience providing case management or utilization management of members with autism spectrum disorder or complex psychiatric/SUD cases preferred. Knowledge & Skills * Knowledge of DSM V or most current diagnostic edition. Ability to identify medically necessary Autism and ABA care and collaborate with providers to implement solutions that directly influence the quality of care. * Exceptional communication, interpersonal, problem solving, facilitation and analytical skills. * Action oriented with strong ability to set priorities and obtain results. * Collaborator - builds team spirit and interdepartmental rapport, using effective problem solving and motivational strategy. * Open to change, comfortable with new ideas and methods; creates and acts on new opportunities; is flexible and adaptable. * Embrace the diversity of our workforce and show respect for our colleagues internally and externally. * Excellent organizational planning and prioritizing skills. * Ability to effectively utilize time management. * Proficiency utilizing Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs. Ability to learn new systems as technology advances. Fully Remote: This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence's physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania. IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability. Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.

Blue Cross is hiring Clinical Support Representatives to work alongside our clinical review team as part our Utilization Management department. Job responsibilities include verifying member benefits, provider networks, and prior approval requirements for authorization of services all in a call center type environment. Work hours are Monday-Friday 8:00-4:30. Experience working in the medical field as an office assistant, medical coder, or Licensed Nursing Assistant is preferred and familiarity with medical terminology is helpful. * Location: If hired, there will be a six week in-person training program at our Berlin, Vermont office. Representatives will continue working on-site five days per week until proficiency has been demonstrated in performing the role independently. After this time, employees within a 50-mile radius will be expected to come to the office on Wednesdays with flexibility to work remotely the rest of the week. * Starting pay at $20.00 per hour. * Six-week paid training. * Target start date is Wednesday, February 18. Robust benefits package including: * Health insurance (including vision) * Dental coverage (free to employees) * Wellness Program with a $500 year-end incentive * 401(k) with employer match * Life Insurance * Disability Insurance * Combined time off (CTO) - 20 days per year + 10 paid holidays * Tuition reimbursement * Student Loan Repayment * Dependent Caregiver Benefits * And more! Diversity, Equity, and Inclusion: Blue Cross VT is committed to creating an inclusive environment where employees respect, appreciate, and value individual differences, both among ourselves and in our communities. We welcome applicants from all backgrounds and experiences to join us in our commitment to the health of Vermonters, outstanding member experiences, and responsible cost management for all the people whose lives we touch. Learn more about our DE&I commitment at **************************************************************** Complete job description attached to ADP posting

Your Role The Pharmacy Analytics & Finance team is responsible for supporting the Pharmacy Reimagined strategy in addition to traditional actuarial functions of claim reserves and cost trends. The Pharmacy Medical Informaticist, Senior Principal will report to the Senior Director, Actuarial Management and support the Pharmacy Team's strategic objectives in contract negotiations, pricing for self-funded employer groups, formulary changes, product development, and initiative evaluation.

Under the direction of the Care Management Manager, the Health Coach functions as the primary nurse to provide both health coaching and case management services to members across the continuum of health ranging from health promotion to end-of-life. Health coaches collaborate on care plan development and coordination with members and physicians by screening, assessing, planning, facilitating, monitoring and giving input when adjustment is needed, and advocating for the member on an individual basis. Health coaches use clinical and motivational interviewing skills to assess member's need and establish mutually agreeable goals while supporting member in developing self-management skills in adopting positive behavior changes. Health Coaches work with the member to identify and address barriers to member's adherence to standards of evidence-based medicine. The health coach facilitates communication between the patient, family, and members of the health care team while acting as an educator and link between the patient, providers and the plan, ensuring high quality, cost-effective services are delivered. Helps members coordinate care and navigate the healthcare system. Duties and Responsibilities: * Functions as a primary nurse for members across the continuum of health and health-related services including information and support for lifestyle improvement, acute symptoms, treatment decisions, targeted health conditions, chronic conditions and complex conditions. * Engages with the members ranging from coaching to intensive case management with the goal to develop and support the member's ability to self-manage. * Provides appropriate clinical coaching support to members placing in-bound calls seeking assistance with acute symptoms, chronic conditions and/or health information regarding, specific topics. * Conducts appropriate surveys/assessments to proactively identify needs. Develops appropriate care plans and establishes goals. Assessment includes working with member/family/significant other to identify barriers of adherence to the physician's plan of care as well as achieving lifestyle improving goals. Continues to work with member via on-going telephonic communication to achieve the agreed upon goals. * Proactively incorporates lifestyle improvement and prevention opportunities into member interactions and coaching. * Contacts member's physician when needed especially in more complex medical situations requiring case management intervention to facilitate care coordination. * Monitors the quality of service, seeking member/family input. Communicates safety issues to manager and utilizes the occurrence screening for quality-of-care tracking. * Identifies on-line, telephonic and community-based resources that can assist the member in achieving and maintaining their personal health goals. Assist the member in accessing those services. In addition, assist in maximizing the use of member's benefits and ensuring coordination of services and outcomes. * Provides exceptional customer service. * Maintains and communicates accurate information in associate self-serve program. * Attends educational programs/training to maintain state license, CCMC licensure and updated knowledge of Health Coach process. * Ensures all activities are documented and conducted in compliance with applicable regulatory requirements and accreditation standards. * Other duties as assigned. Qualifications: * Current, active, and unrestricted Pennsylvania (PA) or multi-state Registered Nurse licensure. * Three years any of combination of clinical, case management and/or disease/condition management experience. * Exceptional communication and problem-solving ability. * Ability to work flexible hours. * Basic computer skills. * Strong clinical knowledge. * Current, active, and unrestricted Pennsylvania (PA) Registered Nurse licensure. * Three years any of combination of clinical, case management and/or disease/condition management experience. * Exceptional communication and problem-solving ability. * Ability to work flexible hours. * Basic computer skills. * Strong clinical knowledge. Fully Remote: This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence's physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania. At Independence Blue Cross, all qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability. Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.

Your Role The People & Engagement Technology team is a critical member of the IT Applications organization and is responsible for providing technical and functional leadership for multiple HR Technology products in the Corporate Platform. It provides product and system solutions to support digital transformation, automation, application security, regulatory compliance, and end-user support. The Senior Manager, People & Engagement Technology will report to the Senior Director, People & Engagement Technology. In this role you will be a strategic leader that is solution-driven and results-oriented and will work collaboratively across the enterprise to evaluate vendor solutions, design, build, and implement technology solutions, and manage and enhance deployed applications. The ideal candidate will also bring expertise in AI-driven HR solutions, technical integrations, and emerging HR technology trends to enhance automation, analytics, and overall HR technology strategy.

Resp & Qualifications CANDIDATES MUST LIVE IN THE MD, DC, VA AREA IN ORDER TO TRAVEL INTO THE OFFICES AND FOR CLIENT MEETINGS AND STAFF MEETINGS. ACTIVE HEALTH AND LIFE LICENSE IS REQUIRED. PURPOSE: This position is responsible for renewing/growing a book business which includes complex accounts with indemnity and managed care medical products, ancillary/specialty products, and life products. This position drives revenue and manages current and prospective relationships to ensure success with products. Leads sales initiatives and strategies within their assigned territory. Achieves sales and profitability objectives by effectively managing new and existing accounts. You will be working with the Middle Market team on the 51-99 market segment. ESSENTIAL FUNCTIONS: * Ensures that each assigned account renews annually and aggressively pursues growth within groups by developing and implementing account specific benefit and financial strategies. * Manages and develops a set of assigned accounts to increase productivity and sales of products, as well as identifies potential customers and sets approach strategies. * Develops strong and long-term client relationships. * Takes ownership of territory team initiatives and ensures deadlines are met. * Resolves issues and handles client complaints quickly and effectively. * Gets feedback and suggests ways to increase customer engagement. QUALIFICATIONS: Education Level: Bachelor's Degree in Business, Finance or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience. Licenses/Certifications Required: * Current health and life license for the jurisdictions of Maryland, DC, and Virginia. Experience: 5 years of healthcare sales experience. Preferred Qualifications: * Experience in a similar sales position with a competitor or another Blue Cross Blue Shield plan. Knowledge, Skills and Abilities (KSAs): * Knowledge and understanding of CRM and other client management tools. * Strong customer service orientation. * Ability to recognize, analyze, and solve a variety of problems. * Excellent communication skills both written and verbal. Travel Requirements: Estimated Amount: 50-80% This position is expected to travel to see clients and prospective clients. Salary Range: $80,000 - $130,000 Salary Range Disclaimer The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements). Department Renewal 100-999 MD Equal Employment Opportunity CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information. Where To Apply Please visit our website to apply: ************************* Federal Disc/Physical Demand Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs. PHYSICAL DEMANDS: The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted. Sponsorship in US Must be eligible to work in the U.S. without Sponsorship #LI-KL1

The role ensure Plans' operations handle customer interactions accurately and promptly, leaving a positive brand impression. Execute audit programs and validate reported results. Present updates and recommendations at various events. Contribute to strategic planning by developing materials, presentations, and documentation. Create and improve standard operating procedures for departmental functions. Interact extensively with Plan staff at all levels, requiring diplomacy in difficult conversations. Influence local and national Plan operations. Responsible for overall Plan execution of the Operational Audit Programs. This includes auditing Plans' local and inter-Plan claim processing, local customer service processing, and enrollment processing in accordance with applicable program. Analyze performance results and lead cross-functional meetings with Plan stakeholders in order to facilitate the development and completion of action plans for each performance program. Lead in the development and administration of various audit initiatives/programs that impact internal and external stakeholders. Provide Plans education and support by helping them to understand and properly execute operational and audit requirements in both formal and informal settings on a scheduled or ad-hoc basis. This includes providing face-to-face training, webinars, handling the Help Desk, one-on-one meetings, and collaborating with other BCBSA staff. The posting range for this position is:$92,788.00-$105,000.00 Qualifications Education Required Bachelor's Degree in a business-related discipline or equivalent work experience Experience 5+ Years related work experience Required Knowledge Skills and Abilities Ability to manage and adapt to multiple, changing priorities. Demonstrated proficiency in the Microsoft Office suite and Internet technologies. Demonstrated research and analytical skills (quantitative and qualitative). Demonstrated presentation and communication skills both oral and written. Knowledge of BlueCross Blue Shield and Inter-Plan Programs. #LI-Remote The posted salary range is the lowest to highest salary we, in good faith, believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the hiring range and this hiring range may also be modified in the future. A candidate's position within the hiring range may be based on several factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, shift, travel requirements, and business or organizational needs. This job is also eligible for annual bonus incentive pay. We offer a comprehensive package of benefits including paid time off, 11 holidays, medical/dental/vision insurance, generous 401(k) matching, lifestyle spending account and many other benefits to eligible employees. Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

Your Role The Behavioral Health Care Management Clinician, Senior helps members with behavioral health needs navigate the health care system for linkages to behavioral health providers, treatment, and programs. The Behavioral Health Care Manager will offer support in assessing members' emotional and psychological well-being and providing resource coordination, crisis intervention, substance abuse, and with any behavioral or mental health referrals. The Behavioral Health Care Manager will be available to physicians and nurse care managers as a consultant for patients with complex psychosocial needs. The position requires an intensive focus on crisis intervention and counseling, problem-solving and conflict resolution, patient and family management, interdisciplinary collaboration, psychosocial assessments, education, advocacy, and community resource linkages.

Your Role The Stellarus Customer Success Team drives customer value realization and long-term adoption of Stellarus solutions through strategic partnerships, delivering proactive guidance, and ensuring measurable business outcomes. The Strategic Account Manager, Customer Success will report to the Senior Director, Customer Success. In this role you will work with our health plan customers orchestrating alignment between business, product, and technology teams to deliver measurable impact. You are the central strategic leader responsible for the entire post‑sale client lifecycle-from adoption and value realization to renewal and expansion. Your mission is to embed Stellarus as an indispensable technology partner by deeply understanding our customers' business, aligning our solutions to their strategic objectives, and delivering quantifiable clinical and financial outcomes. This role requires a rare blend of strategic acumen, deep healthcare industry expertise, commercial ownership, and executive‑level relationship management. You will manage not just the business relationship but also the technical, operational, product, and support components-partnering closely with both product and technology teams to deliver results. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together, we will achieve our mission to enhance the health and well-being of the people and communities we serve. We are seeking a Senior Payment Integrity Auditor to lead the most complex and high-risk audit assignments, ensuring claim payment accuracy and compliance with established billing and coding parameters. This role serves as a subject matter expert (SME) for internal audit staff, provides provider education, and mentors associates on proper audit and claims accuracy methods. The Senior Auditor also identifies new audit opportunities, oversees vendor work, and plays a critical role in fraud detection and process improvement. Responsibilities: * Address the most problematic and complex audit assignments to identify claim overpayments in accordance with established billing and coding parameters. * Ensure claim payment accuracy through sound audit review methods and practices, including: * Claim payment evaluation * Medical chart review * Claim payment data analysis * Assessment of organizational contractual parameters * Serve as work, technical, and project subject matter expert for internal IBC audit staff. * Identify new audit areas through screening and analysis of audit samples. * Identify and refer potential provider fraud or abuse to management. * Interact with providers to clarify clinical issues, documentation, and billing practices. * Document and substantiate billing discrepancies and negotiate resolution when appropriate. * Initiate and verify claim adjustments, maintain comprehensive audit documentation, and prepare statistical data for leadership reporting. * Serve as vendor claims processing expert, liaison, or point of contact to ensure successful achievement of vendor deliverables. * Provide provider education and guidance to associates on proper audit and claims accuracy methods. * Perform duties of Auditors as required and mentor junior team members. Qualifications - External * Education: Bachelor's degree or equivalent. * Certifications (Preferred, Not Required): RHIA, RRA, CCS / CCS-P / CCS-H, ART, CPC, CORT, or RN. * Experience: * Minimum 5+ years of relevant experience in healthcare auditing, coding, or compliance. * Knowledge & Skills: * Extensive knowledge of healthcare provider audit methods, provider payment methodologies, clinical aspects of patient care, medical terminology, and medical record/billing documentation. * Demonstrated analytical and investigative skills. * Working knowledge of project and work management methods and practices related to provider audit. * Technical Skills: * Working knowledge of MS Office (Excel, Word, Outlook, SharePoint, Access, etc.). * SQL or database knowledge a plus. * Excellent communication, negotiation, and leadership abilities. Fully Remote: This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence's physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania. IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability. Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app

Your Role The Stellarus Product Management team defines technology products and brings them to market to help Stellarus's health plan customers improve cost, quality, experience and growth. The Product Manager - Payment Integrity will report to the Senior Director of Product Management, Cost of Care. In this role you will own and drive the product definition and product roadmap for Stellarus's Payment Integrity solutions throughout our Product Development Lifecycle, working closely with product managers for other related products. You will lead a cross-functional Product Squad that governs the product, identifies and writes product requirements, and manages a backlog for the product. You will have responsibility for the success of our product and our customers who use the product.

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together, we will achieve our mission to enhance the health and well-being of the people and communities we serve. We are looking for a meticulous and analytical Payment Integrity Auditor to ensure accurate claims payment, uphold compliance with regulatory standards, and drive financial integrity through detailed chart reviews and collaborative audit processes." Responsibilities: 1. Perform medical chart reviews to ensure provider billing adherence to medical policies and claims payment policies. 2. Review inpatient charts to validate DRG assignment based on ICD-10-CM and ICD-10-PCS coding. 3. Ensure compliance with CMS guidelines, payer policies, and official coding rules. 4. Perform Readmission audits to identify related admissions per claims payment policy criteria. 5. Provide detailed clinical and coding rationale to support audit findings. 6. Collaborate with Providers and Medical Directors to resolve audit disputes. 7. Initiate, verify, and reconcile claim adjustments. Maintain audit documentation. 8. Perform other duties of the Payment Integrity Auditor as required. Qualifications: 1. Bachelor's degree in a health care-related field or business-related discipline preferred. 2. Current credentials of CPC, RN, or RHIT/RHIA/CCS. 3. Strong knowledge of medical terminology and ICD-10-CM/PCS coding guidelines. 4. Understanding of Inpatient Prospective Payment System (IPPS), MSDRG, and regulatory requirements and/or Outpatient Prospective Payment System (OPPS). 5. Inpatient Medical Chart Review experience is required. 6. Analytical and detail-oriented with strong problem-solving skills. 7. Excellent communication skills: verbal and written. 8. Intermediate knowledge of MS Office: Excel, Word, Outlook. Fully Remote: This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence's physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania. IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability. Must have an Android or iOS device that is compatible with the free Microsoft Authenticator app

Our organization is looking for dynamic individuals who love to learn, thrive on innovation, and are open to exploring new ways to achieve our goals. If this describes you, we want to speak with you. You can help us achieve our vision to lead nationally in innovating equitable whole-person health. The Care Management Coordinator, Medical Review conducts post service reviews on medical claims and cases to ensure medical criteria has been met in accordance with current Company medical policies and medical management guidelines for inpatient, outpatient, surgical and diagnostic procedures including out of network services. This position is within the Claims Medical Review team. Responsibilities/Duties * Reviews provider submission of medical records for specific services that have been processed through system automation and require documentation to determine if additional payment is warranted. * Reviews specific medical services during the claims adjudication process against medical policies and medical management guidelines to ensure criteria has been met and provides direction to claims processing area. * Conducts analysis review of post payment claims against current medical policy and medical management guidelines * Identifies claims/services that require medical records review retrospectively * Works with Hospitals and Professional providers to obtain medical records to conduct retrospective reviews * Reviews medical records for identified claims/services to ensure medical criteria based on policies and guidelines have been met * Identifies and refers cases in which the plan of care/services are not meeting established criteria to the Medical Directors for further evaluation determination * Collaborates with appropriate areas of the Company including Care Management, Medical Policy, CFID, Appeals, Clinical Vendor Management and Claims Operations. * Summarizes and tracks all analyses performed and reports to Management * Identifies and suggests process improvements or potential process efficiencies based on reviews conducted * Participates in key business area projects * Assists with review and maintenance of the Claim Medical Review team's policies, procedures, checklists and documentation as required. * Performs other related duties as assigned Knowledge/Skills/Qualifications * RN license, BSN Preferred * Minimum 3-5 years' experience with medical criteria reviews * Strong knowledge of ICD-10, HCPCS and CPT coding/billing * Claims auditing experience a plus * Proficiency with Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs. Ability to learn new systems as technology advances. * Self motivated, highly organized and detailed oriented as well as problem solving, analytical, verbal and written communication skills are required * Demonstrate the ability to work in a multi-tasking environment Fully Remote: This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence's physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania. IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability. Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.