Blue Cross & Blue Shield Remote jobs - 19 jobs

Resp & Qualifications PURPOSE: The Director, Data Transformation & Portfolio Management, will direct the development and implementation of high-level Data & Analytics strategies and oversee complex organizational change initiatives, involving technology, people, and processes. This role also oversees the portfolio of enterprise D&A initiatives through a scaled agile operating model. ESSENTIAL FUNCTIONS: Strategic Leadership * Define and evolve the D&A transformation roadmap. Establish governance, KPIs, and reporting. Oversee major initiatives and advise senior leadership. Portfolio & Agile Oversight * Manage data portfolio and scaled agile operations across nine domains. Drive workforce planning, talent alignment, and capacity forecasting. Resource & Budget Optimization * Develop resource allocation strategies. Monitor $60M+ budget, ensuring financial rigor and cost-effective delivery in partnership with HR and Finance. Change Management * Champion agile and product-centric models. Foster innovation, accountability, and adoption of new operating practices. People Leadership * Build and lead a high-performing team. Recruit, coach, and develop talent. Set goals, manage performance, and oversee departmental budgets. SUPERVISORY RESPONSIBILITY: This position manages people. QUALIFICATIONS: Education Level: Bachelor's Degree in Computer Science, Information Technology, Engineering, 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. Experience: * 8+ years related professional and management experience; and working at or near executive level. * 15+ years of business experience, preferably in healthcare, with recent executive-level exposure. * 10+ years of progressive leadership managing cross-functional teams and enterprise programs in complex organizations. * Proven expertise in transformation and complex program management. * Strong ability to lead change management and system-thinking discipline. * Background in strategy consulting or as a transformation office executive is a plus. Preferred Qualifications: * 10 years related professional experience. Knowledge, Skills and Abilities (KSAs) * Proven ability to lead large-scale, enterprise transformation programs with measurable impact. * Expertise in enterprise strategy, data/digital transformation, and scaled agile delivery. * Strong skills in workforce planning, portfolio governance, and organizational design. * Exceptional communicator and influencer with senior business and technical stakeholders. * Strategic, collaborative leader focused on driving alignment and delivering results. * Expert communication (written, verbal). * Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging. Salary Range: $161,040 - $298,931 Travel Requirements Estimate Amount: Up to 20% Meetings 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 VP - Data & Analytics Platform 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-HS1

Resp & Qualifications CANDIDATES MUST LIVE IN THE MD, DC, NORTHERN VA AREA IN ORDER TO TRAVEL INTO THE OFFICES AND FOR CLIENT MEETINGS. PURPOSE: This position is accountable for increasing enrollment, converting to, and retaining Individual ACA business. Responsible for managing strategies that support all distribution channels to build market share in the CareFirst operating area for Individual ACA plans. The incumbent serves as a subject matter expert between CareFirst and principal contracted brokers and General Agencies for marketing, sales, regulatory guidance and enrollment related to products targeting the Consumer Government Programs ACA Individual market. ESSENTIAL FUNCTIONS: * Establishes, develops and maintains business relationships with current and prospective brokers in the Individual ACA market segment to generate new business and retain current business, ensuring market growth goals are achieved. * Identifies broker training needs including products, eligibility, and enrollment processes and coordinates with Training division to develop training documentation to be used. Responsible for instructing brokers, General Agencies and their staff on the use of resources provided by CareFirst to assist the brokers and General Agencies with managing their business. * Support planning and engagement in outreach initiatives and public-facing events that promote awareness, drive community engagement, and organizational goals. * Keeps management informed by submitting activity and results reports, such as daily call reports, weekly work plans, and monthly report cards. * Serves as product expert and maintains an in-depth knowledge of ACA products, rules and guidelines. SUPERVISORY RESPONSIBILITY: Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources. QUALIFICATIONS: Education Level: Bachelor's Degree in Business, Marketing 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. Experience: 3 years sales experience. Licenses/Certifications: * Current health and life license for the jurisdictions of Maryland, DC, and Virginia Upon Hire Required. * Annual Medicare Advantage certification testing and CareFirst required Medicare Advantage product testing Required. Preferred Qualifications: * 3 years sales experience in Consumer sales with an emphasis in the ACA market. Knowledge, Skills and Abilities (KSAs) * Presentation negotiation and influencing skills, and the ability to interface with all levels of prospects and internal associates. * Understanding of broker/administrator system. * Sales motivation, compensation, knowledge of current issues in the health insurance industry. * Generating sales leads and developing external relationships to increase market value for the segment. * Significant travel, and ability to work some evenings and weekends. * Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. * Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. * Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging. Travel Requirements: Significant travel required, including travel out of state. Must have a valid driver's license and transportation to travel throughout service area. Salary Range: $53,600 - $87,100 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 Medicare Sales 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

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.

Resp & Qualifications CANDIDATES MUST LIVE IN THE MD, DC, NORTHERN 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 more complex accounts with indemnity and managed care medical products, ancillary/specialty products, and life products. You will be working with Public Sector accounts with various funding arrangements and plan sponsors within state, municipal and school boards ranging in girth from 100 to 100,000+ contracts. 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. 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. SUPERVISORY RESPONSIBILITY: Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources. QUALIFICATIONS: Education Level: Bachelor's Degree in Business, Finance or related field RO 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. Experience: 8 years healthcare sales. Preferred Qualifications * Sales experience in the public sector markets with an emphasis on strategic, retention and consultative selling. * Experience in a similar sales position with a competitor or another Blue Cross Blue Shield plan is preferred. Knowledge, Skills and Abilities (KSAs) * Knowledge of underwriting principles; group health/life insurance financial/funding mechanisms; stop loss, medicare advantage, wellness, clinical, managed care and point solutions, healthcare delivery systems, including pricing methodologies and cost reimbursement mechanisms for both self-funded and fully insured business. * 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. * Must be able to contribute to membership retention and growth as an active participant in our customer-centric, performance-based culture. * Must be able to develop cross-selling strategies to drive specialty product portfolio adoption and member engagement in products while also creating margin growth and additional revenue streams through a diverse product portfolio. * In a consultative fashion, must be able to work with groups, consultants and brokers to better engage membership in CareFirst products and service, delivering on our whole health value proposition. * Must be able to identify and collaborate with internal resources to deliver a differentiated client experience that meets or exceeds their needs and expectations. Licenses/Certifications: Current health and life license for the jurisdictions of Maryland, DC, and Virginia Upon Hire Required. Travel Requirements: 60% This position is expected to travel to see clients within the CareFirst region. Salary Range: $89,600 - $145,600 (Base Salary Range is based on education, experience & internal equity + Sales Incentive) 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 National Accounts DC 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

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.

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. Schedule: Full time: 5 days (Mon-Fri, 8:30-5p), on-call requirement: Saturday and Sunday full workday, approx. every 12 weeks, depending on number of MDR's. Part Time: 2-3 days per week (8:30a-5p), on-call requirement: 1 Saturday full workday, approx. every 12 weeks, depending on number of MDR's. Receive a comp day for days worked The Medical Director serves as a physician leader responsible for promoting the delivery of safe and effective medical care in the most cost-effective way for the health plans offered by Independence Blue Cross and subsidiaries. There are multiple elements of discrete work that may fall under the role including: Utilization Management The physician directly supports Utilization Management and Care Management and other business activities where involvement of a physician is determined to be in the best interest of Independence. The Medical Director will be responsible for rendering coverage and payment determinations based on the terms and conditions of the health plans for which Independence serves as claims administrator, and on the terms and conditions of contracts executed between Independence and networks of participating health care providers. The Medical Director will exercise sound decision making based on clinical guidelines for best practices, a strong knowledge of clinical medicine, the practical realities of the delivery of health care in the state of Pennsylvania, and a thorough understanding of the principles of population health, quality management, patient safety and health insurance. The Medical Director will be expected to effectively collaborate with professional staff, senior leadership, management and associates and with external partners to promote the delivery of cost-effective health care across all lines of business. Required Qualifications and Experience: * We require a Medical Doctor or Doctor of Osteopathy degree from a medical school or osteopathic medical school recognized by the American Association of Medical Colleges (AAMC), the American Osteopathic Association (AOA), or the World Health Organization (WHO). * Has an unrestricted and unencumbered Pennsylvania license to practice clinical medicine or osteopathic medicine. * Current Board Certification by ABMS or AOBMS - family medicine, internal medicine or pediatrics board certification preferred * Ability to successfully complete Independence Blue Cross credentialing process 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.

Resp & Qualifications CANDIDATES MUST LIVE IN THE MD, DC, NORTHEN VA AREA IN ORDER TO TRAVEL INTO THE OFFICES AND FOR CLIENT MEETINGS AND STAFF MEETINGS. PURPOSE Manages and supports the sales growth and retention of assigned Account Consultants for Mid-Market (51-99) market segments. Conducts sales and service to assigned accounts. Monitors the development and implementation of strategic long-term customer relationships. Achieves targeted Retention Sales goals for the unit. ESSENTIAL FUNCTIONS * Develops account strategies in accordance with overall strategy. Works with the team and Brokers to maximize retention and growth. Manages the Renewal support/service functions essential to day-to-day account, service, productivity, implementation and retention. * Develops account goals and business plan with customer. * Conducts regular reviews of business performance, promotion strategies, and planograms. * Forecasts, budgets, and tracks account revenues and cost for a single account. * Responsible for staff development and ongoing monitoring of metrics to measure performance. * Reporting responsibilities for team Retention, Incentive and Books of Business for Consultants. QUALIFICATIONS Education Level: Bachelor's Degree in Business, Finance or related field. In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience. Experience: * 5 years sales experience. * 1 year supervisory experience or demonstrated progressive leadership experience. Licenses/Certifications: * Current health and life license for the jurisdictions of Maryland, DC, and Virginia is required. Preferred Qualifications * Experience in a health care setting in sales. Knowledge, Skills and Abilities (KSAs) * Strong presentation skills. * Strong negotiation and relationship building skills. * Excellent communication skills both written and verbal. * Microsoft Applications. * Knowledge and understanding of CRM, Excel and Salesforce, and other client management tools. Salary Range: $112,000 - $189,000 (Base Salary Range is based on education, experience & internal equity plus this role offers a Sales Incentive). 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 51-99 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

Under the direction of a Supervisor, Health Resources Center, the Precertification Specialist processes Behavioral Health precertification requests in accordance with established corporate guidelines and in compliance with all state and federal regulations. Major Activities: * Answers incoming telephone calls in a high-volume Call Center environment from members and health care professionals regarding requests for precertification of behavioral health services. * Verifies member eligibility by accessing multiple eligibility systems * Verifies participation status of professional and facility providers, by product and state utilizing multiple database systems including but limited to the National Provider Identification (NPI) Registry * Processes precertification requests from members and providers received telephonically, via fax or the Provider portal per department guidelines * Obtains all clinical information including procedure and diagnosis codes * Enters all pertinent data in the appropriate computer system * Approves selected services per departmental guidelines * Identifies precertification requests that warrant a medical necessity review * Identifies potentially investigative/experimental procedures * Adheres to the departmental standards for staff time, after call work, attendance, and non-queue productivity * Adheres to the corporate quality customer-focused professionalism and accuracy standards * Responds to all forms of communication promptly and as necessary * Performs additional duties as assigned Qualifications * Excellent organizational, interpersonal, verbal, and written communication skills required * Detail oriented with an ability to accept and respond to change. * Proficiency utilizing Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs. * Ability to learn new systems as technology advances Education and Experience: * Bachelor's degree preferred, but not required * Previous experience in social work or related field recommended * Previous customer service experience is required * Previous medical insurance experience is highly recommended, behavioral health experience a plus * Coding knowledge recommended. 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.

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.

Resp & Qualifications PURPOSE: We are seeking a Senior Technical Program Manager to lead cross-functional programs that modernize the enterprise data ecosystem, advance interoperability capabilities, and drive the retirement of legacy platforms. This role will oversee the end-to-end delivery across architecture, engineering, governance, IT partners, and business stakeholders to ensure scalable, compliant, and future-ready data solutions. ESSENTIAL FUNCTIONS: * Program Leadership & Execution: Own multi-year roadmaps for enterprise data modernization, interoperability capabilities, and legacy system decommissioning. Manage complex cross-domain programs spanning multiple technical domains and platforms, establishing milestones, identifying risks and dependencies, and coordinating transparency through dashboards, KPIs, and executive updates. * Legacy System Retirement: Lead structured deprecation programs for legacy and redundant platforms. Define transition states, migration strategies, cutover and go-live plans, and manage governance requirements associated with the system sunsetting. * Stakeholder & Change Management: Partner with executives, business owners, technology leaders, PMO, and architecture teams to align on strategy and delivery. Facilitate cross-functional workshops to define requirements, resolve conflicts, and prioritize tradeoffs. Lead change management, communication planning, and operational readiness. * Data &Interoperability Delivery: Drive the delivery of interoperability capabilities (including FHIR, HL7, APIs, event streaming) by partnering with architecture and engineering. Ensure alignment or program initiatives to enterprise and industry standards to promote governance, quality, security, privacy, and regulatory compliance. * Technical Depth: Able to translate between business needs and technical implementation across the full data value chain. Review technical design documents, data flow architectural diagrams. SUPERVISORY RESPONSIBILITY: Leads a team utilizing a matrix management system. QUALIFICATIONS: Education Level: Bachelor's Degree in Business Management 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 Upon Hire Preferred: Certified Project Management Professional (PMP)-PMI PgMP - Program Management Professional Experience: * 10 years experience in a program operation role with * 3 years in program management capacity Preferred Qualifications: * Demonstrated experience in leading large program initiatives in the healthcare domain such as EHR, care/utilization management, or data warehouse platform migrations or product launches. * Familiarity with FHIR, implementation guides, payer-to-payer, prior auths, clinical data exchanges, or CMS interoperability mandates. * Background in a technical architecture or engineering function. * Hands-on experience with cloud data platforms (Snowflake, Azure, Confluent/Kafka, MuleSoft). * Experience orchestrating vendor ecosystems, SI partners and offshore/nearshore teams. * Strong understanding in security, privacy, engineering, and regulatory compliance for healthcare data. Knowledge, Skills and Abilities (KSAs) * Comprehensive understanding of data architecture concepts, including data models, pipelines, metadata, lineage, quality, and governance. * Strong familiarity with interoperability standards such as FHIR, HL7, X12, RESTful APIs, and event driven integration patterns. * Working knowledge of cloud-native data platforms, microservices, streaming technologies, and legacy system architectures. * Awareness of regulatory frameworks relevant to healthcare data exchanges (HIPAA< CMS, ONC, NCQA). * Ability to define and execute multi-year modernization and deprecation roadmaps across multiple technology domains. * Skilled in translating business outcomes into technical implementation plans, sequencing strategies, and dependency maps. * Proficiency in creating clear program artifacts (OKR/KPIs, RAID logs, dashboards, cutover plans) and communicating with executive leadership. Salary Range: $137,040 - $244,959 Travel Requirements Estimate Amount: 10% 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 Data & Analytics Platform 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-HS1

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. Customer Service Representative Responsibilities: * Attains and keeps current with the knowledge and skills required to provide information, service, and assistance in response to all inquiries. * Available as assigned to accept calls in a professional and courteous manner. * Determines the nature of the call and takes all possible action, including research, completing forms, or any follow-up, to expeditiously ensure the provision of accurate information, service, and assistance upon first contact. * Acquire knowledge of all claims systems applications and member service systems. * Prepares and forwards appropriate requests to operating areas to accomplish action required as a result of the inquiry. * Checks internal system inboxes to ensure completion and follow-up action. Obtains required information and makes a callback when necessary to complete action on inquiries. * Meets quality performance standards and works within established time frames. * Acknowledges each piece of mail and responds to written inquiries either by telephone or letter as required in a professional manner. * Advises the Supervisor when any of the above accountabilities cannot be performed because of matters beyond the control of the Representatives, such as system, procedural, or administrative errors that indicate a trend. * Ability to ask effective probing questions and deescalate challenging member inquiries and concerns. * Supports the area in the ongoing use of TQM principles in a continuous quality improvement process. * Performs other duties as assigned. * The Call Center is open from 8:00am-11:00pm EST-we ask for flexibility with these hours as business needs dictate our business hours. We do offer an 8% Shift differential for those working the later shifts. * Ability to work from home, which includes high-speed wi-fi capability of at least 400 Mbps and a quiet, confidential workspace. * May assist junior staff as needed 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. Customer Service Representative Responsibilities: * Attains and keeps current with the knowledge and skills required to provide information, service, and assistance in response to all inquiries. * Available as assigned to accept calls in a professional and courteous manner. * Determines the nature of the call and takes all possible action, including research, completing forms, or any follow-up, to expeditiously ensure the provision of accurate information, service, and assistance upon first contact. * Acquire knowledge of all claims systems applications and member service systems. * Prepares and forwards appropriate requests to operating areas to accomplish action required as a result of the inquiry. * Checks internal system inboxes to ensure completion and follow-up action. Obtains required information and makes a callback when necessary to complete action on inquiries. * Meets quality performance standards and works within established time frames. * Acknowledges each piece of mail and responds to written inquiries either by telephone or letter as required in a professional manner. * Advises the Supervisor when any of the above accountabilities cannot be performed because of matters beyond the control of the Representatives, such as system, procedural, or administrative errors that indicate a trend. * Ability to ask effective probing questions and deescalate challenging member inquiries and concerns. * Supports the area in the ongoing use of TQM principles in a continuous quality improvement process. * Performs other duties as assigned. * The Call Center is open from 8:00am-9:00pm EST-we ask for flexibility with these hours as business needs dictate our business hours. We do offer an 8% Shift differential for those working the later shifts. * Ability to work from home, which includes high-speed wi-fi capability of at least 400 Mbps and a quiet, confidential workspace. * May assist junior staff as needed Qualifications: Minimum High School diploma or equivalent * Two years of college education preferred. Experience: * 2-3 years proven work experience with customer contact preferred * Experience in the hospitality, healthcare, or pharmaceutical industry * Exceptional customer service, problem-solving skills. * Bilingual a plus * Strong communication skills * Demonstrated strong interpersonal skills * With minimal supervision, demonstrates the ability to research and analyze information from various systems, make responsible decisions, and demonstrate customer-focused professionalism at all times. 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 following states: Houston, TX, Columbus, OH, or 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. 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.

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

Resp & Qualifications PURPOSE: The Small Group Existing Business Sales Consultant serves as the primary strategist and revenue leader for a defined territory of small group brokers, and their associated employers. Unlike traditional account service roles, this position will not manage day-to-day broker service issues those are handled by the Broker Service Team. Instead, the consultant is responsible for retention strategy, renewal positioning, revenue optimization, and broker ecosystem engagement. This role mirrors the strategic expectations of our manager-level sales leadership: driving clarity, elevating performance, and ensuring our market voice is consistent, compelling, and effective. The consultant functions as the internal authority on the assigned relationships the person the broader organization turns to for insights on portfolio health, competitive threats, renewal decisions, and growth strategy. ESSENTIAL FUNCTIONS: Relationship Ecosystem Management * Organize brokers and employer groups into relationship ecosystems, identifying influence networks, key producing clusters, and regional patterns. * Lead relationship engagement across these ecosystems, ensuring brokers receive consistent, strategic messaging and renewal support, not just performing service work. * Act as the strategic face of CareFirst to broker partners, elevating our value proposition and shaping how we show up in the market. * Partner closely with the Broker Service Team, who owns service delivery and issue resolution, ensuring a seamless and coordinated experience. * Facilitate escalations appropriately through service teams while maintaining focus on higher-order strategy, messaging, and relationship management. Renewal Excellence & Competitive Positioning * Lead renewal strategy conversations with brokers and internal teams; articulate competitive positioning, product differences, and value drivers. * Prepare and deliver compelling renewal presentations, tailored narratives, and portfolio-level insights for brokers and employer decision-makers. * Partner with underwriting, product, operations, sales leadership, and market strategy to ensure renewals are timely, accurate, and aligned with enterprise goals. * Strengthen consistency and quality of renewal execution by identifying process gaps, improving handoffs, and proposing enhancements to cross-functional workflows. Internal Influence, Communication & Thought Leadership * Serve as the internal subject matter expert on the assigned relationships, serving as trusted partner to brokers for insights, risks, or needed actions. * Communicate market feedback, broker sentiment, competitor behavior, and emerging threats to sales leadership and cross-functional partners. * Support the creation of strategic sales messaging, broker communications, market-level talking points, and competitive counter-strategies. * Participate in staff meetings, pipeline reviews, strategic planning sessions, and quarterly business reviews to represent the voice of the existing book. * Contribute to a high-performance, accountable culture by modeling preparation, clarity, rigor, and professional presence. 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 Upon Hire Required: * Current health and life license for the jurisdictions of Maryland, DC, and Virginia. Experience: 3 years sales/healthcare experience in a similar sales position. Preferred Qualifications: * Experience in a similar sales position with a competitor or another Blue Cross Blue Shield plan is preferred. Knowledge, Skills and Abilities (KSAs) * Knowledge and understanding of CRM, Salesforce, 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. * Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging. Salary Range: $60,800 - $98,800 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 SM SBU New Business 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

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.

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. At Independence, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve. The Autism Case Management (ACM) Program Case Manager position functions as a primary clinical resource for members living with challenges related to Autism Spectrum Disorder related. The ACM Case Manager collaboratively engages members in strengths-based approaches to facilitate increased understanding of each member's behavioral and physical health needs. Through this process, members gain the skills and supports to facilitate lifestyle improvement thereby enabling a holistic, person-centered approach to addressing their overall health. The ACM Case Manager provides support, guidance, and education to help members and their families better cope with acute symptoms and make treatment decisions based on their individual preferences and needs. The ACM Case Manager facilitates the development of a care plan tailored to address the member's identified strengths and needs. This also includes coordination and collaboration with the member's health care team to better enhance advocacy and communication around the delivery of high-quality, cost-effective services including ongoing screening, assessment, treatment planning, treatment delivery and monitoring of a member's mental and physical health conditions. In order to maximize access to care, the ACM Case Manager teaches and guides members to better navigate the behavioral and physical health care systems, providing advocacy when needed. Case Managers have a strong understanding of the behavioral change process and use motivational interviewing techniques and other interventions to help the member resolve any barriers to change thereby improving adherence to evidence-based, cost-effective treatment and services. Key Responsibilities: § Telephonically engages members who have ASD to clinically address challenges and identify barriers to care. § Engages with members, and their family where applicable, to identify strengths, needs and goals, in order to facilitate development of care plans. Provides follow-up when clinically appropriate and requested by the member. § Works with the BCBAs, Medical Directors and other team members to shape care planning and provision § Serves as a liaison and support, working within the member's health care team when needed especially when members are involved in complex behavioral health situations that often warrant changes to the member's care plan. § Identifies and provides coaching for members to access online, telephonic and community-based resources that can assist the member in achieving and maintaining their personal behavioral and physical health goals. In addition, assist in maximizing the use of member's benefits and ensuring coordination of services and outcomes. § Provides appropriate clinical assessment, intervention and support to members who actively seek behavioral health support via inbound calls. Qualifications: Active PA Registered Nurse (B.S.N. Preferred), LCSW, LSW, LMFT, LPC or BCBA required Experience, Knowledge, & Skills: * Minimum of 3-5 years post licensure experience in an integrated care setting, hospital or other health care setting. * 3 years' experience working with children and/or adults with autism, experience providing case management or utilization management to members with autism spectrum disorder * Knowledge of ASD, DSM-5 and ASAM * Strong understanding of the Social Determinants of Health and Motivational Interviewing approaches to help member's move past barriers to improved behavioral and physical health outcomes. * Ability to work independently using critical thinking to resolve complex behavioral, medical, and psychosocial issues with our members. * Excellent assessment and engagement skills and ability to adapt clinical skills while using telephonic and virtual means. * Embraces new ideas and methods; creates and acts on new opportunities; is flexible and adaptable. * Ability to meet individual productivity goals in order to provide quality, cost-effective services and support to members. * 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. * Excellent organizational planning and prioritizing 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.

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.

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 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. The Payment Integrity Auditor is responsible for conducting complex and high-risk audit assignments to ensure claim payment accuracy and compliance with established billing and coding parameters. This role applies advanced audit methodologies to identify claim overpayments, validate payment integrity, and support organizational goals through detailed analysis and provider engagement. Responsibilities: * Address problematic and complex audit assignments to identify claim overpayments in accordance with established billing and coding parameters. * Identify payment methods and factors used in reimbursing targeted claims and apply appropriate audit/payment accuracy methods. * Evaluate and audit samples in summary and in detail to select audit claims. * Examine medical and billing records to identify provider patterns that determine or influence payment. * Interact with providers to clarify clinical issues, documentation, and billing practices. * Document and substantiate billing discrepancies to providers and negotiate resolution when appropriate. * Initiate and verify claim adjustments, maintain audit documentation, and prepare statistical data. * Serve as vendor claims processing lead, liaison, or point of contact to ensure achievement of vendor work. Qualifications: Education: o Bachelor's degree or equivalent. Certifications (Preferred, Not Required): * Registered Health Information Administrator (RHIA) * Registered Records Administrator (RRA) * Certified Coding Specialist - Physician/Hospital (CCS / CCS-P / CCS-H) * Accredited Record Technician (ART) * Certified Professional Coder (CPC) * Certified OR Technician (CORT) * Registered Nurse (RN) Experience: o Minimum 3 years of relevant experience in healthcare auditing, coding, or compliance. Knowledge & Skills: * Working knowledge of healthcare provider audit methods and provider payment methodologies. * Understanding of clinical aspects of patient care, medical terminology, and medical record/billing documentation. * Demonstrated analytical and investigative skills. * Strong proficiency in MS Excel and audit tools. * Excellent communication and negotiation 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.