Manager of Quality Improvement
Neighborhood Health Plan of Rhode Island Job In Smithfield, RI
Job Details Smithfield, RI - Smithfield, RI Full Time Bachelors Degree Occasional Daytime ManagementDescription
The Manager of Quality Improvement supports the Senior Manager of Quality Improvement and Accreditation by leading the identification and design of company-wide quality improvement (QI) efforts and provides direction to the implementation of QI efforts through cross-functional work teams, department workgroups and/or other ad hoc teams. This position leads the organization's efforts to obtain the highest level of performance in quality measures including NCQA Medicaid Health Plan Ratings, Medicare Stars and pay for performance programs.
Duties and Responsibilities Responsibilities include, but are not limited to, the following:
Works with internal committees and inter-departmental work groups to identify and prioritize innovation and improvement opportunities. Helps align senior leader support for suggested organizational changes/projects and presentation to selected audiences
Monitors performance of HEDIS and Stars measures and develops processes to support continuous quality improvement
Leads and oversees the development and implementation of programs and interventions to optimize HEDIS, Stars and other quality performance programs
Evaluates effectiveness of quality improvement initiatives, including providing recommendations to internal and external stakeholders
Develops and monitors provider quality score cards to ensure ongoing provider engagement in quality improvement activities to maximize performance in HEDIS and Medicare Stars measures
Provides subject matter expertise in support of the agenda and work of quality improvement committees
Engages in on-going performance management of staff including coaching, mentoring, development, training and succession planning to include hiring and termination decisions
Serves as the subject matter expert on models for quality improvement methods, standards, and applications, and for data management and display related to QI
Assists other departments with business process/quality improvement projects
Supports the analysis of annual HEDIS data and the information on performance from NCQA Health Plan Stars Rating to help identify high-priority improvement and innovation opportunities for the organization
Leads cross-functional inter-departmental team which plans, organizes, coordinates and identifies improvement opportunities in support of achieving the highest level of NCQA Health Plan Stars Rating for Medicaid, Medicare and commercial products
Responsible for the organization's bi-annual filings with the Office of the Health Insurance Commissioner (OHIC) to obtain Network Plan and the Benefit Determination and Utilization Review Certifications
Maintains current knowledge of all present and future quality mandates from regulatory bodies including NCQA, Executive Office of Health and Human Services, Centers for Medicare and Medicaid Services and other regulatory bodies
Other duties as assigned
Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents
Qualifications
Required:
Bachelor's degree in Business Administration, Health Care Administration, Public Health or related field
Five (5) years' experience in a managed care organization or a health care-related organization, including experience with Medicaid and/or commercial lines of business
Knowledge and experience in data collection, specifications, and key performance drivers of all Stars measures
Demonstrated knowledge in using quality improvement tools and techniques to drive performance
Two (2) or more years of direct experience facilitating and/or leading quality improvement or business process improvement efforts, preferably related to health care
Two (2) or more years of experience overseeing teams/management experience
Experience with NCQA accreditation survey requirements for health plan, HEDIS quality measures and with state and federal health care regulations applicable to managed care organizations
Experience in providing leadership to formal and informal group processes supporting priority setting and program implementation
Experience in management and supervision of staff, including staff with technical responsibilities
Must be detailed-oriented, able to exercise sound judgment in making decisions, able to work independently in a flexible environment and able to manage multiple projects in an efficient, timely manner
Strong ability to conduct both quantitative and qualitative analysis and identify opportunity for improvement as well as activities to address the opportunities
Strong ability to represent the company in statewide initiatives
Strong presentation, project management, interpersonal and oral and written communication skills
Strong ability to foster an environment of learning and empowerment
Strong computer skills required (Excel, Word, PowerPoint, MS Project research)
Preferred:
Masters degree in Business Administration, Health Care Administration, Public Health or related field
Demonstrated experience with Medicare Stars
Experience developing and implementing pay for performance programs including value-based approach
National Association of Healthcare Quality certification as a Certified Professional in Healthcare Quality/Organizational Excellence (CPHQ/OE) or similar QI training
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
Provider Data Integrity Specialist (40414)
Neighborhood Health Plan of Rhode Island Job In Smithfield, RI
The Provider Data Integrity Specialist maintains the integrity of all demographic and reimbursement information for the companys provider network, ensuring that all processes and procedures are completed in accordance with established state and federal laws and regulations, company policies and procedures and contracted terms.
Duties and Responsibilities
* Responsible for accurate and time maintenance of provider configuration in accordance with state and federal laws and regulations.
* Serves as the subject matter expert regarding provider configuration in the claims processing system(s) and its impact to claims processing and provider reimbursement.
* Monitor proposed/approved changes to state and federal law, assess the impact on provider configuration and institute changes as required to remain compliant with regulations governing the company.
* Assist in the timely maintenance of the Provider Directory; the Provider Manual; the provider pages on the company website and the provider communication network software in accordance with state and federal laws and regulations.
* Work cross-organizationally (e.g. Credentialing department, Claims department, etc.) to ensure identified issues that affect provider claims processing and provider reimbursement are corrected in an accurate and timely manner.
* Responsible to extract, review and provide quality control on provider configuration to ensure consistency in all applicable software.
* Manage and respond to all provider credentialing request.
* Ensures all provider with our vendors is monitored and kept current. Performs thorough quality review of all completed provider data updates.
* Creates and maintains all Provider Data Integrity desktop procedures.
* Claim processing oversight and impact analysis on all adjustments made due to an update in provider data.
* Responsible to identify internal and external opportunities for provider education.
* Responsible to identify and, as approved, implement opportunities for process improvement both internally and externally.
* Works on special projects as assigned by Manager
* Performs other duties as assigned by Manager
* Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.
Qualifications
Qualifications
Required:
* Bachelors degree or Associates degree or a minimum four (4) years experience in health insurance or health care operations or related field in lieu of a degree
* Minimum of three (3) years data entry experience
* Extensive knowledge of health insurance, insurance laws and regulations, claims processing, medical and insurance terminology and procedure and diagnostic codes
* Knowledgeable of provider, facility and reimbursement mechanisms
* Proven ability to work cross-organizationally to achieve the goals of the organization and department
* Knowledge of the provider credentialing and contracting process as it relates provider affiliations and reimbursement
* Knowledge of cross-functional software module; Electronic Data Interchange (EDI) claim submission, provider remittance advice and provider timely filing protocols
* Proven ability to analyze problems, draw relevant conclusions and work with all levels of staff to implement appropriate change
* Strong oral and written communication skills and the ability to understand and interpret complex and/ or technical information
* Strong data analysis skills
* Strong Microsoft Excel skills
Preferred:
* Bachelors degree
* Detailed knowledge of government healthcare program regulations
* Experience working with Cognos
* Knowledge of Microsoft SharePoint
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
Marketing & Communications Intern- Summer 2025
Providence, RI Job
Please email HR_Talent_************************** if you are a candidate seeking a reasonable accommodation for the application and/or interview process.
Jump into the new world of health insurance:
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), our business is healthcare. But our focus is on improving lives. Be part of a team that is large enough to make a difference but small enough to be innovative. Work in a rapidly changing field. Take a chance to be creative. Move outside the status quo. Shape new ideas with the power of a national brand behind you.
Join others who know diversity is strength:
We appreciate and celebrate everything that makes us unique: age, national origin, citizenship status, perspectives, experiences, physical or mental disability, military status, race, ethnicity, religion, gender, sexual orientation, gender identity and/or expression. Our diversity strengthens us as an organization and helps us better serve an increasingly diverse Rhode Island population.
Why this job matters:
The Marketing & Communications Team is looking for a Student Intern. The student will be exposed to communication staff during their internship. The student will have the ability to shadow and sit in on planning meetings as well as have designated projects.
What you will do:
Support the execution of marketing and communications strategies to drive brand and marketing communication campaigns across all available channels.
Collaborate with cross-functional business stakeholders to assess and identify marketing needs, implement campaign strategies, measure and analyze marketing performance against campaign goals, socialize outcomes and attribution related to campaign execution
Support the execution of marketing and communications campaigns for the promotion of the organization's products and programs.
Collaborate within the department to assess and identify existing and future marketing needs and develop solutions. Assist in the development of digital and content marketing to support campaign and brand goals and objectives.
Assist in managing deliverables from marketing campaign strategy through execution.
Participate in meetings with external agencies and internal partners to develop relationships, gathering and curating the necessary data to tell the complete marketing story through metrics and analysis.
Participate in department initiatives and projects.
Perform other duties as assigned.
What you need to succeed:
Strong project management skills
Knowledge of marketing communications techniques
Excellent organizational skills and ability to successfully prioritize multiple tasks
Verbal and written communications skills
Good problem-solving skills
Ability to interface with employees at all levels
Ability to handle multiple priorities/projects
Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:
In-office: onsite 5 days per week
Hybrid: onsite 2-4 days per week
Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia
Graphic Design Student Intern
Providence, RI Job
Please email HR_Talent_************************** if you are a candidate seeking a reasonable accommodation for the application and/or interview process.
Compensation: $18-$25 hourly
Jump into the new world of health insurance:
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), our business is healthcare. But our focus is on improving lives. Be part of a team that is large enough to make a difference but small enough to be innovative. Work in a rapidly changing field. Take a chance to be creative. Move outside the status quo. Shape new ideas with the power of a national brand behind you.
Join others who know diversity is strength:
We appreciate and celebrate everything that makes us unique: age, national origin, citizenship status, perspectives, experiences, physical or mental disability, military status, race, ethnicity, religion, gender, sexual orientation, gender identity and/or expression. Our diversity strengthens us as an organization and helps us better serve an increasingly diverse Rhode Island population.
Why this job matters:
The Marketing & Communications Team is looking for a student Graphic Design Intern. The student will be exposed to marketing communication staff during their internship. The student will have the ability to shadow and sit in on planning meetings as well as have designated projects.
What you will do:
Support the design and production of print and digital materials, which may include video, photo, web, and other electronic media, for use in marketing communications.
Collaborate with creative team and communications staff to ensure designs meet project needs.
Ensure that design and layouts adhere to corporate and brand standards.
Prepare materials for print production.
Maintain archive of images, photos, or previous work products.
Support the execution of marketing and communications campaigns for the promotion of the organization's products and programs.
Collaborate within the department to assess and identify existing and future marketing needs and develop solutions.
Assist in the development of digital and content marketing to support campaign and brand goals and objectives.
Assist in managing deliverables from marketing campaign strategy through execution.
Participate in meetings with external agencies and internal partners to develop relationships, gathering and curating the necessary data to tell the complete marketing story through metrics and analysis.
Participate in department initiatives and projects.
Perform other duties as assigned.
What you need to succeed:
Working knowledge of concept development, design, and production processes for a variety of vehicles including print and digital media
Knowledge of Adobe Creative Suite and appropriate multimedia software as needed, on a Mac platform
Excellent organizational skills and ability to successfully prioritize multiple tasks
Verbal and written communications skills
Good problem-solving skills
Ability to interface with employees at all levels
Ability to handle multiple priorities/projects
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national origin, disability, veteran status, sexual orientation, genetic information and gender identity or expression.
The law requires an employer to post notices describing the Federal laws prohibiting job discrimination based on race, color, sex, national origin, religion, age, equal pay, disability, veteran status, sexual orientation, and genetic information and gender identity or expression. Please visit ********************************************* to view the "EEO is the Law" poster.
Other details
Pay Type Hourly
Budget, AP, and Cash Ops Student Intern - Summer 2025
Providence, RI Job
Please email HR_Talent_************************** if you are a candidate seeking a reasonable accommodation for the application and/or interview process.
Schedule: Hybrid
Compensation: $18-$25 hourly
Jump into the new world of health insurance:
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), our business is healthcare. But our focus is on improving lives. Be part of a team that is large enough to make a difference but small enough to be innovative. Work in a rapidly changing field. Take a chance to be creative. Move outside the status quo. Shape new ideas with the power of a national brand behind you.
Join others who know diversity is strength:
We appreciate and celebrate everything that makes us unique: age, national origin, citizenship status, perspectives, experiences, physical or mental disability, military status, race, ethnicity, religion, gender, sexual orientation, gender identity and/or expression. Our diversity strengthens us as an organization and helps us better serve an increasingly diverse Rhode Island population.
Why this job matters:
The Strategic FP&A team is looking for a student intern to work within our finance department. The student will support day to day functions of the Budgets, AP, and Cash Receipts teams and assist with special projects
What you will do:
Assist in conducting mathematical analyses to provide financial information to decision-makers.
Help analyze decision alternatives using quantitative methods and apply appropriate theories and mathematical models under supervision.
Learn from and work with experts across the organization to ensure data matches past results and future expectations
Learn about preparing the annual budget, ensuring it complies with stated requirements and accurately reflects Cost Accounting Standards and other applicable regulations.
Help prepare reports on account trends and analysis of accounts payable and receivable.
Research, calculate and analyze cost accounting records. Learn about preparing reports of fluctuations in expenses on a monthly basis to support variance analysis on financial statements, budget-to-actual and executive reports.
Assist in preparing financial results or recommendations for various audiences, from finance staff to senior management, using spreadsheets and presentation graphics.
Assist the team with department initiatives and projects.
Perform other duties as assigned.
What you need to succeed:
Ability to apply and interpret sound accounting principles during daily work
Ability to apply and interpret standard mathematical concepts
Ability to interpret and draw conclusions from numerical data
Ability to research data, identify trends and recommend appropriate actions
Detail oriented
Ability to work successfully in a matrix environment
Demonstrated written and verbal communications skills
Ability to exercise sound judgment
Ability to take initiative in finding solutions to difficult and/or sensitive problems
Ability to establish and maintain strong working relationships with various stakeholders
Ability to organize work efficiently to meet established time and quality standards
Good organization skills
Good time management skills
Proficiency with Microsoft Suite of products, i.e., Word, Excel, PPT, etc
Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:
In-office: onsite 5 days per week
Hybrid: onsite 2-4 days per week
Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national origin, disability, veteran status, sexual orientation, genetic information and gender identity or expression.
The law requires an employer to post notices describing the Federal laws prohibiting job discrimination based on race, color, sex, national origin, religion, age, equal pay, disability, veteran status, sexual orientation, and genetic information and gender identity or expression. Please visit ********************************************* to view the "EEO is the Law" poster.
.
Other details
Pay Type Hourly
Providence College Internship Program 2025 - Commercial Product
Providence, RI Job
Please email HR_Talent_************************** if you are a candidate seeking a reasonable accommodation for the application and/or interview process.
Schedule: Hybrid
Compensation: $18-$25 hourly
Jump into the new world of health insurance:
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), our business is healthcare. But our focus is on improving lives. Be part of a team that is large enough to make a difference but small enough to be innovative. Work in a rapidly changing field. Take a chance to be creative. Move outside the status quo. Shape new ideas with the power of a national brand behind you.
Join others who know diversity is strength:
We appreciate and celebrate everything that makes us unique: age, national origin, citizenship status, perspectives, experiences, physical or mental disability, military status, race, ethnicity, religion, gender, sexual orientation, gender identity and/or expression. Our diversity strengthens us as an organization and helps us better serve an increasingly diverse Rhode Island population.
Why this job matters:
Support Product & Sales Advancement initiatives. Key responsibilities include sourcing and analyzing data to inform product decisions, assist product managers with key deliverables during the annual portfolio implementation project, and lead strategic initiative efforts to advance sales efforts.
What you will do:
Source market and competitive intelligence
Analyze results and summarize findings to inform product strategy
Assist with processing and reviewing BCBSRI national account renewals
Review claims utilization data for national accounts
Enhance and produce sales reporting
Assist with the development of fact bases and ad-hoc reporting
Attend meetings, take minutes and be able to report back to the team, as needed
Support strategic initiatives
Develop of process, procedures, and workflows
Produce benefit summaries to reflect the updates to the Large Group and Small Group 2026 portfolios
Review and track product collateral
What you need to succeed:
Matriculating status from Providence College
Highly motivated
Reliable
Professional speech and demeanor
Working knowledge of Microsoft Office including Excel, PowerPoint, and Word. Salesforce knowledge is helpful but not required.
General computer proficiency
Knowledge of general mathematical principles, including ratios and percentages
Good presentation skills with the ability to interact effectively with a diverse employee population
Computer, typing, keyboard, and Internet skills are essential
Ability to work independently
Time management skills
Ability to collect, analyze, and organize large amounts of data
Ability to communicate effectively, both verbally and in writing
Ability to coordinate multiple projects simultaneously and be flexible and adaptable to changing priorities
Ability to write reports, business correspondence, and procedure manuals
Ability to define problems, establish facts, and draw valid conclusions
Ability to interpret technical instructions in mathematical or diagram form and deal with several abstract and concrete variables
Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:
In-office: onsite 5 days per week
Hybrid: onsite 2-4 days per week
Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia
Claims Reconsideration Coder
Neighborhood Health Plan of Rhode Island Job In Smithfield, RI
Job Details Smithfield, RI - Smithfield, RI Full Time Undergraduate Certificate Occasional Daytime Some ExperienceDescription
The Claims Reconsideration Coder (CRC) is a multidisciplinary Certified Professional Coder accredited through the American Academy of Professional Coders or Certified Coding Specialist accredited through American Health Information Management Association. This role will evaluate medical record documentation by abstracting the pertinent information that supports the services billed to allow a determination for payment or denial on claim submissions that meet the criteria for a medical note review. Relies on sound review methods applied to the content of the medical notes, benefits, payment policies, clinical medical policies, NCCI edits, CMS, coding manuals (CPT, HCPC, ICD-10), and other industry supported resources required to independently make their determination. This role attends bi-weekly meetings with the Medical Director to present claims that require a medical necessity determination. When separate reimbursement is appropriate, the CRC will make the necessary adjustment. If the request is denied, they compose an adverse determination response to the provider. The Coder uses self-directed, decision making and problem solving that directly impacts financial outcomes and results.
Duties and Responsibilities:
Responsibilities include, but are not limited to:
Responsible for all aspects of Claim Reconsideration Requests and Contracted Provider Administrative Appeals including reviewing, resolving, adjusting, and development of written communication to providers
Independently abstract and interpret of all medical notes required to determine if the services billed are supported for reimbursement using current industry standard coding, CMS guidelines, plan benefits, contractual reimbursement terms, and Neighborhood policies
Communicate adverse determination to Provider via written correspondence
Responsible for identification, review and reporting of inaccurate billing practices and trends gleaned from reconsideration determinations and coding/billing knowledge
Work in conjunction with the Medical Director on issues of medical necessity and resolution
Work in collaboration with Provider Relations team to provide claim examples for appropriate provider education. Collaborates to create and revise educational materials.
Responsible for reporting of potentially fraudulent or abusive billing patterns to the Special Investigation Unit
Maintain audit documentation and cumulative reports with prior determinations for utilization as a repository
Continuously maintain repository of periodicals, website links and tools used in making determinations
Perform any necessary adjustments on the claim(s) affected directly by reconsideration determinations in the HealthRules system
Request appropriate adjustment on the claim(s) affected to the Claims BPO
Identify process improvements and collaborates with appropriate personnel and departments as needed for implementation
Maintain annual Continuing Education Units (CEU) required to sustain their knowledge and accreditation certificate from the AAPC or AHIMA. This includes remaining up to date on coding changes and guidelines.
Perform other duties and/or special projects as assigned
Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents
Core Company-Wide Competencies:
Communicate Effectively
Respect Others & Value Diversity
Analyze Issues & Solve Problems
Drive for Customer Success
Manage Performance, Productivity & Results
Develop Flexibility & Achieve Change
Job Specific Competencies:
Collaborate & Foster Teamwork
Attenion to Detail & Quality Improvement
Exercise Sound Judgement & Decision Making
FDR Oversight: N/A
Travel Expectations:
N/A
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
Qualifications
Qualifications
Required:
Associate's degree or equivalent, relevant work experience in lieu of a degree
Current certification from the American Academy of Professional Coder's (AAPC) Certified Professional Coder or American Health Information Management (AHIMA) Certified Coding Specialist
Three (3) or more years of direct application of coding, billing, and reimbursement mechanisms
Three (3) or more years of prior claims processing and/or medical billing experience
Prior experience with claims editing software
Prior experience with claims billing or payment systems
Demonstrated working knowledge of medical record documentation requirements and interpretation as it relates to claim reimbursement
Demonstrated knowledge of NCCI, CPT, HCPC, ICD-10-CM, and ICD-10-PCS coding edits
Knowledge of established norms and guidelines in the industry
Basic understanding of contract implementation and working knowledge of contract language
Experience with Optum Encoder, similar coding software/website
Knowledge of HIPAA standards and CMS guidelines
Excellent ability to effectively prioritize and implement tasks/special projects within deadlines
Intermediate skills working with Microsoft Office products including Outlook and PDF documents
Superior analytical and problem-solving skills
Extreme attention to detail, highly developed organizational skills, and ability to prioritize assignments
Strong written communications skills
Positive and professional attitude, with a strong emphasis on working as a team
Preferred:
Bachelor's degree
Prior experience within a claims operations area in a Health Care environment
Working knowledge of Fraud, Waste and Abuse Policies and Practices
Quality Management Analyst
Providence, RI Job
Please email hr_business_******************* if you are a candidate seeking a reasonable accommodation for the application and/or interview process.
Compensation: $71,700 - $107,700
Jump into the new world of health insurance:
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), our business is healthcare. But our focus is on improving lives. Be part of a team that is large enough to make a difference but small enough to be innovative. Work in a rapidly changing field. Take a chance to be creative. Move outside the status quo. Shape new ideas with the power of a national brand behind you.
Join others who know diversity is strength:
We appreciate and celebrate everything that makes us unique: age, national origin, citizenship status, perspectives, experiences, physical or mental disability, military status, race, ethnicity, religion, gender, sexual orientation, gender identity and/or expression. Our diversity strengthens us as an organization and helps us better serve an increasingly diverse Rhode Island population.
Why this job matters:
Identify quality issues through analysis of data and evaluation of clinical or business processes. Facilitate the design, implementation, and maintenance of quality initiatives that improve operational business processes or member healthcare and safety. Partner and collaborate with provider network to improve performance, collaboration, and stakeholder relationships.
What you will do:
Identify clinical quality issues and business process improvement opportunities through data analysis and internal process evaluation. Conduct root cause analyses and develop interventions to enhance clinical or business processes.
Analyze, develop, execute, and manage the PCP Quality Incentive Program to ensure alignment with business goals and industry standards.
Serve as a resource to internal and external stakeholders, supporting the application of quality management principles and fostering a culture of continuous quality improvement. Become a subject matter expert on incentive programs, HEDIS measures, CMS Star Rating Program, and quality best practices.
Collaborate and manage the collection of quality data from provider partners to ensure accuracy and completeness, driving performance improvement and meeting organizational goals.
Develop, enhance, and manage provider quality education materials.
Prepare documentation, data, presentations, and reports for management, external partners, and quality oversight committees.
Conduct provider site visits as needed to support providers and practices on quality, incentive programs, coding, medical record collection, etc
Utilize various data and information systems supporting these activities. Work with technical staff on maintenance of data, and the utilization of various IT systems to maximize the clinical and business benefits of effective information management.
Develop and implement educational programs for new and existing employees in the division to increase knowledge and skill development in areas including, but not limited to, quality management principles, model and tools, change management.
Participate in department initiatives and projects.
Perform other duties as assigned.
What you need to succeed:
Bachelor's degree in Nursing, Health Administration, Business, or related field, or an equivalent combination of education and experience
Three to five years experience in clinical quality activities or experience in business process improvement activities
Active and unrestricted RN license issued by a state participating in the Nurse Licensure Compact (NLC)
Knowledge of clinical quality management principles or business process improvement techniques
Facilitation skills
Understanding of medical terminology
Knowledge of regulatory and accrediting standards including, but not limited to NCQA, URAC, DOH, DHS, CMS
Advanced analytical skills, with the ability to interpret and synthesize complex data sets
Good business acumen and political savvy
Knowledge of business process improvement techniques and strategies
Excellent verbal and written communications skills
Negotiation skills
Presentation skills
Decision-making skills
Good problem-solving skills
Ability to interface with employees at all levels
Ability to effectively navigate ambiguous situations with limited direction
Excellent organizational skills and ability to successfully prioritize multiple tasks
Ability to handle multiple priorities/projects
Extras:
Certified Professional in Healthcare Quality (CPHQ) designation or equivalent certification
Experience in program development and quality improvement
Experience with HEDIS, NCQA, and CMS
Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:
In-office: onsite 5 days per week
Hybrid: onsite 2-4 days per week
Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national origin, disability, veteran status, sexual orientation, genetic information and gender identity or expression.
The law requires an employer to post notices describing the Federal laws prohibiting job discrimination based on race, color, sex, national origin, religion, age, equal pay, disability, veteran status, sexual orientation, and genetic information and gender identity or expression. Please visit ********************************************* to view the "EEO is the Law" poster. Other details
Pay Type Salary
EPMO Student Intern- Summer 2025
Providence, RI Job
Please email HR_Talent_************************** if you are a candidate seeking a reasonable accommodation for the application and/or interview process.
Compensation: $18-$25 hourly
Jump into the new world of health insurance:
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), our business is healthcare. But our focus is on improving lives. Be part of a team that is large enough to make a difference but small enough to be innovative. Work in a rapidly changing field. Take a chance to be creative. Move outside the status quo. Shape new ideas with the power of a national brand behind you.
Join others who know diversity is strength:
We appreciate and celebrate everything that makes us unique: age, national origin, citizenship status, perspectives, experiences, physical or mental disability, military status, race, ethnicity, religion, gender, sexual orientation, gender identity and/or expression. Our diversity strengthens us as an organization and helps us better serve an increasingly diverse Rhode Island population.
Why this job matters:
The EPMO Portfolio directors and managers support achievement of BCBSRI's strategic objectives and metrics through management of the strategic and “keep the lights on”/mandate projects and programs. The successful candidate will serve as an intern, working directly with the portfolio managers, to support ongoing administrative and process improvement initiatives within the EPMO. This intern will work closely with the CAST Shared Services/EPMO leadership team to support and enhance our oversight and reporting practices to ensure that the EPMO is providing best practice support that ensures consistent delivery and execution of initiatives. This work will include, but is not limited to, assisting in creation of executive dashboards, reviewing and posting key documentation, updating outdated materials such as job aides, and facilitating and/or leading internal EPMO improvement initiatives. In this role, the intern will have the opportunity to learn and work with components of an established Project Delivery Life Cycle (PDLC) by providing direct hands-on support to the portfolio manager and project manager of one of BCBSRI's 2025 major strategic initiatives.
What you will do:
Provide administrative support to the portfolio directors and managers, taking an active role in the creation of EPMO leadership reporting such as the monthly portfolio dashboards, Operating Committee materials and targeted leadership project updates. Actively participate in the EPMO reporting improvements initiative as directed by portfolio manage.
Support the change management process by assisting with review of change request materials submitted by the project managers for approval, maintain the change request log and posting approved change requests. Work with the portfolio managers and the SharePoint support team as needed to help transform and automate this manually intensive process.
Assist the portfolio managers with their portfolio budget reviews. Intern may be asked to review and analyze project and/or portfolio level reports and/or detailed financial transactions to help the portfolio managers ensure accurate portfolio budgets and to proactively identify potential risks.
Assist the portfolio managers with their effort to clean up and redesign the EPMO SharePoint site to make it a current, user-friendly, informative site.
Provide research and administrative support to enable the transformation of the EPMO PDLC from its current state to a more streamlined process that aligns with BCBSRI's LEAN initiatives. This work will include:
Researching best practices, scheduling, facilitating, and documenting work sessions/meetings & reviewing and updating PDLC templated and job aides to align with updated processes
Support team in 2025 agile journey planning
Participate in intern group project and divisional scheduled engagements where possible, including community events or visits to BCBSRI retail stores
Perform other duties as assigned
What you need to succeed:
Comfortable working in a team-oriented environment
Ability to lead and facilitate meetings and/or work sessions
Critical thinking skills
Creativity
Strong organization & time management skills
PowerBi experience preferred
Manager of Enrollment Medicare (40839)
Neighborhood Health Plan of Rhode Island Job In Smithfield, RI
The Manager of Enrollment Medicare is responsible for managing enrollment activities for Medicare-Medicaid (MMP) and D-SNP lines of business. This position is accountable for the accurate, timely processing and data entry of Medicare enrollments, re-enrollments and disenrollment, subsequent maintenance of the enrollment data, compliance with regulatory requirements relating to enrollments and disenrollment, filing of applications, and other related documents. This position works with internal and external stakeholders to address broad, complex enrollment issues. The position also maintains high visibility and accountability to both state and federal entities including the Executive Office of Health and Human Services (EOHHS), Department of Health (DOH), and Centers for Medicare and Medicaid Services (CMS).
Duties and Responsibilities
Responsibilities include, but are not limited to, the following:
* Preparation and timely processing of enrollment transactions, management, and maintenance in accordance with CMS regulations.
* Ensures compliance with all applicable policies and procedures.
* Maintenance of strong knowledge of the Enrollment process along with State, Federal, and business regulatory requirements and other state specific applications concerning Managed Care Enrollment
* Engage in on-going performance management of staff including coaching, mentoring, development, training and succession planning to include hiring and termination decisions
* Ensure quality control of data entered into membership data base, as well as timely and accurate dissemination of eligibility data to internal systems and external vendors and delegated entities.
* Serves as the subject matter expert and lead on functional deliverables ensuring optimal efficiency of member enrollment
* Oversees and participates in state, federal, and internal audits, as needed.
* Ensure diligent record keeping and audit trails for all relevant inbound and outbound files
* Establish and keep current all departmental policies and procedures
* Responsible for ensuring timely reconciliation of eligibility files and adjustments to CMS that meet regulatory and health plan requirements, as required.
* Coordinate and manage the generation and mailing of all necessary correspondence relating to enrollment, re-enrollment, and disenrollment in accordance with CMS time frames.
* Partners with vendor management team and the external vendor to ensure service level agreements and regulatory requirements are met.
* Responsible for communicating and following up on files delayed by CMS and/or State or issues with a file that require Health Plan involvement.
* Responsible for ensuring timely reconciliation of eligibility files and adjustments to CMS that meet regulatory and health plan requirements.
* Partners with vendor management team and the external vendor to ensure service level agreements and regulatory requirements are met.
* Other duties as assigned
* Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.
Qualifications
Qualifications
Required:
* Bachelor's degree in Finance, Business or Health related area or equivalent seven (7) + years of experience in Medicare enrollment health care/insurance operations
* Knowledge and experience with CMS Transaction Files and 834 Electronic Data Interchange (EDI)
* Experience managing delivery through vendor relationships via service level agreements and regulatory requirements
* Supervisory experience and proven leadership skills
* Proficiency in Microsoft Office applications including but not limited to Word, Excel, Outlook and various database applications
* Data driven individual experienced in a transactional production environment
* Experience working with technical teams to deliver in support of business objectives
* Demonstrated experience translating business needs into formal Business Requirements Documents (BRD's)
* Experience in leading User Acceptance Testing (UAT), including documentation and tracking of defects
* Experience in monitoring staff production quality and developing staff for quality improvement
* Comfort level and demonstrated experience in managing daily prioritization based on a constantly changing technology and business environment.
* Solution oriented individual with high comfort level in being flexible and nimble to changing business needs
* Strong analytical/problem solving skills
* Ability to convey information/ideas clearly and effectively, both verbally and written
* Proven ability to develop strong, effective working relationships and work teams
* Experienced managing external vendor relationships in the delivery of key business processes
* Demonstrated experience with development and executing operational process improvements
* Ability to develop business cases and complete Return on Investment (ROI) analysis
Preferred:
* MBA or equivalent
* Experienced in or willingness to obtain lean methodology and/or six sigma certification
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
Provider Relations Representative (41660)
Neighborhood Health Plan of Rhode Island Job In Smithfield, RI
This position is responsible for cultivating, maintaining and strengthening relationships with the provider community. In this highly visible field position, the provider relations representative acts as the primary liaison between the organization and its providers including primary care practices, specialists, physician organizations, hospitals, ancillary and long term services and supports providers. Primary responsibilities include establishing positive working relationships with providers, effectively communicating with and educating those providers about the organization and resolving provider inquiries.
Duties and Responsibilities:
Responsibilities include, but are not limited to:
* Develop and maintain strong professional relationships with providers and their staff while functioning as a liaison to the provider community to research and resolve complex provider issues
* Establish regular contact with and visits to provider sites. Visits may include regular operations meetings, staff education, provider orientations, and other events
* Identify opportunities for provider training and education
* Orient providers on Neighborhood's policies related to claims; benefits; clinical programs; referral and authorization; regulatory compliance; billing and payments; complaints and appeals; policies and procedures;
* Take ownership of the provider relationship, ensuring all provider needs and concerns are addressed and resolved
* Work collaboratively departmentally and inter-departmentally to resolve provider issues to ensure an adequate and satisfied provider network
* Manage and respond to a high volume of provider inquiries while ensuring consistent follow through on resolution of issues
* Identify opportunities for improving the provider experience and participate in implementation of provider satisfaction initiatives.
* Work collaboratively departmentally and inter-departmentally to resolve provider issues to ensure an adequate and satisfied provider network
* Participate in departmental and interdepartmental meetings as appropriate and necessary
* Participate in the development of departmental policies, procedures and processes
* Maintain professional growth and development
* Represent organization at provider related events and other initiatives, as necessary
* Responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents
* Other duties as assigned
Qualifications
Qualifications- Required:
* Bachelor's degree in Health Administration, Business Administration, Public Health or a related field or an equivalent amount of education and experience
* Two (2)+ years' experience with a managed care organization or a health care related organization (e.g. HMO, Medicaid, Medicare)
* Two (2)+ years' direct application of coding, billing and reimbursement mechanisms
* Two (2)+ years' experience with facility or professional provider relations
* Experience with commercial, Medicaid or Medicare reimbursement mechanisms
* Intermediate to Advanced skills in Microsoft Office (Word, Excel, Outlook)
* Ability to interact well with individuals on all levels, and maintain a professional image and attitude
* Ability to manage data and processes in multiple platforms
* Ability to work cross-organizationally to achieve the goals of the company and department
* Ability to work independently
* Demonstrated knowledge of billing practices and reimbursement methodologies
* Detail oriented, with the ability to organize and ability to manage multiple projects simultaneously
* Excellent Customer Service Skills
* Excellent written and strong business communication skills (written and verbal) public relations, presentation and facilitation skills
* Strong analytical, problem solving and project management skills
* Understanding of provider and claim operations as they relate to health plans
* Understanding of provider's reimbursement methodologies and contract terms
* Must be able to travel within an assigned territory on a daily basis
Qualifications- Preferred:
* Understanding of claims operations
* Experience in Cognos
* Experience in MedInsight
* Experience in SharePoint
* Experience with commercial, Medicaid or Medicare reimbursement mechanisms
* Knowledge of Quality Improvement Processes (e.g. Lean, Six Sigma)
* American Academy of Professional Coders (AAPC) certification
Technical Analyst
Neighborhood Health Plan of Rhode Island Job In Smithfield, RI
Job Details Smithfield, RI - Smithfield, RI Full Time Bachelors Degree None Daytime Professional / ExperiencedDescription
The Technical Analyst serves as the liaison between software development staff, IT infrastructure, planning teams, business unit stakeholders, on and offshore testing, and operations support team. This position is responsible for the creation and maintenance of technical documentation that support various design and development processes within Neighborhood. The position will collaborate with multiple business lines during the design phase, delivers comprehensive solution documentation, including but not limited to architecture diagrams, process flows, technical requirements, functional design specifications, and data dictionaries. The Technical Analyst understands the solution being built at a low level and collaborates with IS staff to create a work breakdown in various planning tools such as JIRA and MS Project. At times, the position may work upstream from design and development to define business requirements for projects and initiatives.
Duties and Responsibilities:
Responsibilities include, but are not limited to the following:
Assessment of systems, data sources, interfaces, and processes, including participation in recommendations based on the current-state assessment.
Analyze and interpreting business data to creating better business insight and outcomes
Evaluate system changes affecting existing systems, workflows, and users. Identify potential risks, compatibility issues, and required updates. Assess benefits and drawbacks of the changes and prepare a mitigation plan for any identified risks.
Maintains a moderate understanding of the technical and functional architecture of assigned systems and integration
Gather and translate business requirements into technical specifications. Develop and enhance systems documentation.
Perform business process mapping and documents system flows using Visio and other design tools.
Attend project status meetings or standups and facilitate meetings as needed to surface roadblocks including business requirements clarifications, technical hurdles, project risks, and working cross-functionally to reach resolution and move the project forward.
Candidates should be comfortable working in a fast-paced and dynamic environment, contributing to innovative solutions, while demonstrating personal leadership, technical competence, and attention to detail
Liaison with business stakeholders, IT teams, and project managers to ensure clear communication of project objectives and deliverable
Responsible troubleshooting issues and preparing technical documentation for defects
Responsible for working with the QA team to make sure testing is performed for system issues
Knowledge of System Development Life Cycle (SDLC) and Azure DevOps CI/CD
Advise management about system innovations to improve productivity
Perform data analysis and advise on data issues
Identify and promote continuous improvements to both internal IS and business processes.
Coordinate multiple simultaneous projects and initiatives
Can function independently with minimal oversight and direction
Other duties as assigned
Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents
Qualifications
Required:
Bachelor's degree and/or years of relevant work experience and background to equate to the degree
Two (2) + years of technical analysis experience
Exhibit analytical thinking skills, breaking down complex technical issues and identifying optimal solutions
Intermediate to advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook, Visio)
Basic competence in T-SQL and use of SQL Management Studio to query data. Understanding of SQL objects and data types
Familiar with modern technical system architecture, such as Kubernetes, microservices/APIs, event driven data streaming to build robust, resilient and scalable solutions.
Knowledge and experience in JIRA, Confluence, MS Project, Visio
Working knowledge of both Waterfall and Agile methodologies
Ability to create technical requirements, functional designs, end-user docs, process flow diagrams, business requirements, and other documentation
Strong business acumen and political savvy
Ability to think creatively and to drive innovation
Ability to work effectively as both a leader and a member of a team as needed to deliver solutions
Strong organizational and prioritization skills, including organizing the work for others in a team setting
Experience envisioning and delivering continuous improvement ideas in a team setting
Experience working with claims payor systems and possess strong product knowledge of Health Rules Payor, Guiding Care and Source.
Demonstrated ability to manage multiple priorities simultaneously in a deadline driven environment with accurate resource and time estimates
Adept in problem solving and conflict resolution
Preferred
Bachelor's degree
Prior experience building data dictionaries using Dataedo or other automated tools
Prior experience coding or scrum experience on a .NET/SQL development team and PowerBi
Four (4) + years of technical analysis experience
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
Temporary Employee- Nurse Reviewer
Providence, RI Job
Please email HR_Talent_************************** if you are a candidate seeking a reasonable accommodation for the application and/or interview process.
Schedule: Hybrid or Remote Compensation: $33.56 - $50.38 Jump into the new world of health insurance:
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), our business is healthcare. But our focus is on improving lives. Be part of a team that is large enough to make a difference but small enough to be innovative. Work in a rapidly changing field. Take a chance to be creative. Move outside the status quo. Shape new ideas with the power of a national brand behind you.
Join others who know diversity is strength:
We appreciate and celebrate everything that makes us unique: age, national origin, citizenship status, perspectives, experiences, physical or mental disability, military status, race, ethnicity, religion, gender, sexual orientation, gender identity and/or expression. Our diversity strengthens us as an organization and helps us better serve an increasingly diverse Rhode Island population.
Why this job matters:
Optimize member benefits to promote effective use of resources. Conduct pre and post payment review of inpatient admissions, outpatient services, and other procedures to assess the medical necessity and appropriateness of services on-site or in-house. Discuss cases with attending physician and other health care professionals. Prepare and refer concerns to plan Medical Directors.
What you will do:
Conduct pre and post payment review of inpatient admissions, outpatient services, and other procedures to assess the appropriateness and continuity of care.
Apply all aspects of the medical review function, including pre-authorization, concurrent review, screening for quality-of-care issues, and discharge planning. Document rationale for medical decisions made.
Identify at-risk members who would benefit from health management programs through comprehensive health assessments.
Monitor and evaluate patient's plan of care and identify potential issues through telephonic outreach. Recommend appropriate interventions.
Promote member and provider satisfaction. Provide continuity and consistency of care by building positive relationships between member and family, physicians, provider, care coordinator, and health care plan. Represent corporation in a responsible and professional manner.
Participate in department initiatives and projects.
Perform other duties as assigned.
What you need to succeed:
Unrestricted Rhode Island Nursing License
Three to five years acute medical or clinical experience or experience in utilization reviewed.
Valid Driver's License (On-site only)
Understanding of utilization review techniques including all aspects of the medical review function, including pre-authorization, concurrent review and discharge planning
Understanding of health care delivery system access points and services
Correct application of health care management guidelines
Ability to navigate the healthcare delivery system
Advanced analytical skills, with the ability to interpret and synthesize complex data sets
Good business acumen and political savvy
Knowledge of business process improvement techniques and strategies
Excellent verbal and written communications skills
Negotiation skills
Presentation skills
Decision-making skills
Good problem-solving skills
Ability to interface with employees at all levels
Ability to effectively navigate ambiguous situations with limited direction
Excellent organizational skills and ability to successfully prioritize multiple tasks
Ability to handle multiple priorities/projects
Extras:
Bachelor's Degree in Nursing
Certified Case Management certification, Certified Professional Utilization Review certification
Experience working in a managed care/health maintenance organization.
Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:
In-office: onsite 5 days per week
Hybrid: onsite 2-4 days per week
Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national origin, disability, veteran status, sexual orientation, genetic information and gender identity or expression.
The law requires an employer to post notices describing the Federal laws prohibiting job discrimination based on race, color, sex, national origin, religion, age, equal pay, disability, veteran status, sexual orientation, and genetic information and gender identity or expression. Please visit ********************************************* to view the "EEO is the Law" poster.
Other details
Pay Type Hourly
Senior Claims Adjuster
Neighborhood Health Plan of Rhode Island Job In Smithfield, RI
Job Details Smithfield, RI - Smithfield, RI Full Time High School or GED None Daytime Some ExperienceDescription
The Senior Claim Adjuster is responsible for assisting in the day to day managing of claim issues for high profile providers. This role acts as the single point of contact for their assigned accounts for any claim related issue. They are the liaison/advocate between the provider and internal departments. The Senior Claim Adjuster works directly with practice managers, via phone, email and in-person meetings on a regular basis to resolve outstanding claim issues. This role works with our Provider Contracting and Provider Relations departments to assist in managing the operational aspects of the provider relationship, and will attend internal meetings to present their research and findings on claims issues. This role serves as a claims subject matter expert (SME) and is responsible for incoming inquiries regarding current claims and escalated issues. Collaborates in strategic planning for their assigned accounts. Works collaboratively with business and operational units to ensure prompt resolution of open issues. . They assume ownership and accountability for the timely and accurate identification and resolution of claims issues through thorough research using the necessary tools such as a review of provider contracts, benefits, JIRA tickets, CES edits, NCCI edits, correct coding, reporting, testing, and other appropriate tools.
Duties and Responsibilities:
Responsibilities include, but are not limited to:
Serves as the SME and Lead on functional deliverables ensuring optimal efficiency in all areas of responsibility
Tracks and maintains all known issues, including the operational provider issue logs, and implements work plans to improve claims accuracy and systemic issues that decrease efficiency or provider satisfaction.
Conducts extensive research on complex payment inaccuracies and documents root cause analysis and mitigation
Receives and responds timely to correspondence on escalated issues
Performs any necessary claim adjustments for overturned determinations directly in the HealthRules system.
Request appropriate adjustment via AWD to the Claims BPO
Represents Neighborhood to internal and external customers in a professional manner
Attends ad-hoc and regularly scheduled operational meetings with provider community within and outside of the organization
Responsible for documenting deliverables from meetings/calls and providing timely resolution of same.
Collaborates with other departments to root cause and resolve claim payment issues. Opens JIRA tickets as needed.
Provides support and guidance to all Claims teams on identified system issues
Partners with the Documentation Specialist to create desktop procedures
Supports testing of new functions, features, system upgrades and new implementations
Other duties/special projects as assigned
Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.
Qualifications
Qualifications
Required:
Associates degree or equivalent relevant work experience in lieu of a degree
Minimum of five (5) years experience with a managed care organization or a health care related organization (HMO; Medicaid/Medicare)
One (1) or more years experience working in direct relation with the provider community (claim resolution, GAU, provider relations, contracting, etc.)
Strong understanding and experience in all aspects of claims adjudication, processing, and analysis.
Ability to manage multiple projects simultaneously
Demonstrated experience with managing and cultivating strong business relationships with the provider community
Ability to understand business systems and articulate deficiencies and opportunities
Understanding of provider reimbursement mechanisms
Intermediate to Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook)
Basic understanding of contract implementation and working knowledge of contract language
Must exercise excellent judgment and be effective working autonomously and as part of a team
Exceptional listening skills and verbal/written communication skills
Problem solver with strong attention to detail
Extensive knowledge of all Neighborhood products and services, including all key operations and their functions and a familiarity with Medical Management and any other internal department and external vendors.(internal candidate)
Must be knowledgeable of resources available within the organization to resolve both internal and external problems and concerns.
Strong information management skills including the ability to organize information, identify subtle and/or complex service delivery issues that impact customers and the ability to articulate and pursue solutions to problems impacting service
Knowledge of HIPAA standards and CMS guidelines
Preferred:
Bachelors degree
Coding Certification from the American Academy of Professional Coder (AAPC) or American Health Information Management Association (AHIMA)
Prior experience with JIRA issue tracking system or a similar project tracking system
Experience with Optum Encoder or similar coding program/website
Prior Network Management experience
Project Management experience
Core Company-Wide Competencies:
Communicate Effectively
Respect Others & Value Diversity
Analyze Issues & Solve Problems
Drive for Customer Success
Manage Performance, Productivity & Results
Develop Flexibility & Achieve Change
Job Specific Competencies:
Collaborate & Foster Teamwork
Build Relationships & Cultivate Networks
Attend to Detail & Improve Quality
Exercise Sound Judgement & Decision Making
FDR Oversight: N/A
Flexible Work Arrangement:
Yes
Telecommuting Arrangement:
No
Travel Expectations:
N/A
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
Product Development Director - FDSNP
Neighborhood Health Plan of Rhode Island Job In Smithfield, RI
Job Details Smithfield, RI - Smithfield, RI Full Time Bachelors Degree Daily Daytime ManagementDescription
The Product Director - Medicare will provide leadership, oversight, coordination and monitoring of workstreams and activities associated with new Medicare product implementations. The Product Director - Medicare will collaborate with internal partners (including but not limited to: Sales and Marketing, Actuarial/Finance, Operations, Enrollment and Claims) to launch new Medicare products and initiatives which meet company goals and objectives.
This position will serve as the subject matter expert “SME” in a fast-paced environment that leads to progressive decision making based on project/program risk, timelines, budget, and on time deliverables. This position requires time management, through communication, agility, organizational excellence, reporting, high degree of Medicare Advantage knowledge, and finally project/program effectiveness. Responsibilities include ensuring that the new Medicare product meets or exceeds regulatory and accreditation requirements for the Centers for Medicare and Medicaid Services (CMS) and NCQA and is responsible for all implementation workstreams associated with the successful launch and operation of Medicare plans.
The Product Director is responsible for ensuring the performance and success of the company's Medicare product launch, performance standards associated with the product and supporting staff. This position is accountable for all service and operational requirements associated with the product and monitors performance to ensure the plan meets corporate performance benchmarks. The position works collaboratively with and reports directly to the Vice President Medicare-Medicaid Integration.
Duties and Responsibilities Responsibilities include, but are not limited to the following:
Play a pivotal role in the oversight of key product implementation workstreams that integrate key activities, timelines, resources, budget, and track the critical path for assigned project(s). Ensure project workstreams meet CMS and EOHHS requirements.
Manage new product initiatives from concept to implementation and provide ongoing monitoring post-launch.
Actively leads and directs resources across the organization and contracted with the organization to achieve program and contract goals related to Medicare implementation and integration into operations
Function as a subject matter expert (SME) leading effective coordination between organization/department process flows, stand-ups, retrospectives, sprint reviews, design, and planning. Serve as primary liaison for Project Team to key project implementation workstreams
Actively participate in collaborative team environment to educate, coordinate activities, and resolve unique problems with recommended course to action with internal and external partners.
Support efforts to achieve operational excellence in the Medicare Advantage products.
Lead and drive cross-functional implementation priorities to yield results. Simultaneous action at varying stages-initiation, follow through, and completion-on a number of different projects.
Lead and motivate teams on internal and external implementation deliverables. Foster open dialogue within team and build positive team spirit to overcome obstacles.
Ability to anticipate issues and work toward a solution by building consensus within the project team.
Facilitate coordination of the project activities between functional areas and work with senior management to define roles and responsibilities of team members.
Facilitate resolution of conflicts between functional groups and external collaborators while maintaining objectivity.
Oversees the work of staff responsible for program implementation and oversight. Provides leadership and direction to staff, including performance management oversight and employee development.
Serves as representative for the product/program on internal and external committees, as assignee
Other duties as assigned
Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents
Qualifications
Qualifications
Required:
Bachelor's Degree and/or equivalent, relevant work experience in Health Care Management in lieu of a degree
Seven (7) or more years of Medicare experience. Experience is preferred in product management or development roles within the healthcare or managed care industry
Demonstrated success in leading end-to-end product development lifecycles, from concept to launch
Strong analytical and strategic thinking skills, with the ability to synthesize complex information, identify trends, and make date driven decisions
Exceptional communication and collaboration abilities, with the capacity to influence and build relationships with internal and external partners
Knowledge of relevant regulations requirements within the manage care industry
Ability to adapt to a fast-paced and dynamic work environment, with the ability to handle multiple priorities effectively
Excellent quantitative analysis skills, including medical expense budgeting and expense savings
Strong project management and research skills and ability to ensure adherence to goals and deadlines
Strong leadership skills that demonstrate integrity and professionalism
Effective negotiating skills
Solid knowledge of Medicaid and/or Commercial regulatory requirements/standards
Ability to lead and manage in a cross-functional environment
Intermediate to Advanced computer skills required (Microsoft Office suite)
Ability to travel for work. Must have access to reliable transportation. If using personal vehicle, must have valid driver's license and proof of insurance. Frequency of travel: daily
Preferred:
Masters degree
Contract management experience
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
Data Governance Engineer
Neighborhood Health Plan of Rhode Island Job In Smithfield, RI
Job Details Smithfield, RI - Smithfield, RI Full Time Bachelors Degree None Daytime Professional / ExperiencedDescription
The Data Governance Engineer plays a pivotal role in ensuring the integrity, quality, and security of organizational data assets. This position will collaborate with various teams across the organization to establish and enforce data governance policies, standards, and procedures. Responsibilities include identifying data quality issues, implementing data governance frameworks, and driving initiatives to improve data management practices. This role requires a strong understanding of data governance principles, excellent analytical skills, and the ability to communicate effectively with stakeholders at all levels.
Duties and Responsibilities:
Responsibilities include, but are not limited to:
Design, implement, and maintain data governance frameworks, policies, and procedures to ensure compliance with regulatory requirements and organizational standards.
Monitor and assess data quality issues, establish data quality metrics, and develop strategies to improve data accuracy, completeness, and consistency.
Classify data assets based on sensitivity and criticality, establish metadata standards, and implement metadata management processes to enhance data discoverability and usability.
Collaborate with cross-functional teams, including IT, legal, compliance, and business units, to define data governance requirements, resolve data-related issues, and promote a culture of data stewardship.
Ensure compliance with data privacy regulations (e.g., HIPAA) by implementing data access controls, encryption mechanisms, and data anonymization techniques to protect sensitive information.
Evaluate, select, and implement data governance tools and technologies to support data governance initiatives, such as data cataloging, data lineage, and data quality monitoring.
Generate and distribute regular reports on data governance activities, including data quality assessments, compliance audits, and remediation efforts, to senior management and stakeholders.
Identify opportunities for process improvement, automation, and optimization of data governance workflows to enhance efficiency and effectiveness.
Other duties as assigned by Manager
Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.
Qualifications
Qualifications
Required:
Bachelor's degree in computer science, information technology, data management, or a related study, or equivalent combination of education and relevant work experience
Minimum of three (3) years of experience in data governance, data management, or related fields, with a deep understanding of data governance principles, practices, and methodologies
Strong analytical skills with the ability to analyze complex data sets, identify trends, and recommend solutions to improve data quality and governance
Proficiency in data governance tools and technologies, such as data cataloging tools, metadata management platforms, and data quality tools (e.g., Spirion, MS Purview)
Excellent communication skills with the ability to effectively collaborate with stakeholders at all levels, translate technical concepts into business terms, and influence decision-making processes
Knowledge of data privacy regulations (e.g., HIPAA) and experience implementing data privacy and security controls
Excellent communication skills
Strong attention to detail, organizational skills, analytical and problem-solving skills and ability to manage multiple priorities in a fast-paced environment
Preferred:
Experience working in regulated industries (e.g., healthcare) with a focus on data governance and compliance.
Familiarity with data management best practices, data modeling techniques, and data architecture principles.
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
Nurse Practitioner
Neighborhood Health Plan of Rhode Island Job In Smithfield, RI
Job Details Smithfield, RI - Smithfield, RI Full Time Masters Degree Daily Daytime Professional / ExperiencedDescription
Health @ Home, an innovative home-based primary care program, in partnership with the Neighborhood Health Plan of Rhode Island and patients primary care provider team, delivers evidence-based practices that are both high quality and cost-effective to improve the quality of life to Rhode Islands older adult population. Home visits are performed by an interdisciplinary team consisting of Nurse Practitioners, Registered Nurses, and Community Health Workers. Clinical rounds are facilitated by the Medical Director weekly, and collaborates with case management, pharmacy, and behavioral health departments to identify barriers to patients have navigating the health care system, with the goal to reduce hospitalizations, and improve the quality life of NHPRI members.
This roles primary responsibility is to provide a highly coordinated, comprehensive approach to Neighborhoods plan members health care needs by providing patient centric home-based primary care to members that are in need of more tailored care due to chronic medical conditions and social determinants in order to enhance the patient experience, the health of the community, and decrease total medical costs.
The Nurse Practitioner manages the care of members in accordance with the Nurse Practitioner standards of care (assessment of health status, diagnosis, development of plan of care and treatment, implementation of treatment plan and evaluation of member status). Clinical management is conducted in collaboration with other health care team members, including patients primary care provider and team. Performs home-based comprehensive physical assessments of complex and chronically ill members while building trusting relationships. The NP teaches members, families and caretakers how to provide safe, effective care and promote members' optimum function. Uses teaching methods appropriate to the situation, learning needs, readiness and ability to learn, language preference and cultural values and beliefs. Care will primarily be provided in the members home, however, they may provide support in other facilities as needed.
Responsibilities include, but are not limited to the following:
Perform 4-6 daily home visits that utilizes the Institute for Healthcare Improvements, Age Friendly 4M framework to provide evidence based care that aligns with what matters to older adults to better address the challenges in navigating the healthcare systems and improve their quality of life
Evaluates the needs of each member in developing and updating a comprehensive individualized care plan in collaboration with team members, plan member, Primary Care Provider (PCP), specialists and other service providers
Optimize chronic medical conditions, assess home environment and social determinants of health, educate patients and caregivers, and develop proactive care plans
Makes home visits to monitor and track each members clinical status and delivers care in the home
Perform acute care visits for potentially preventable ED transfers and hospitalizations
Communicate and collaborate with primary care provider offices to offer home-visits for their most at risk, complex, vulnerable patients
Continued assessments of the status of identified problems, response to treatment, compliance with the therapeutic regimes and medications as well as progress towards goals
Understand the importance of quality metrics and interpret to improve health outcomes
Delegates care by the registered nurse, community health worker, and behavioral health/social worker
Orders and interprets diagnostic and therapeutic tests relative to members needs
Prescribes and adjusts medications and treatments based on a sound understanding and interpretation of clinical indicators and findings
Help members and caregivers understand their health condition(s) and develop strategies to improve their health and well being
Observes safety and security procedures; reports potentially unsafe conditions
Determines the need for consultation from specialists and make referrals as necessary
Collaborates with multidisciplinary team members by making appropriate referrals to Care Management team and to behavioral health care services
Manages both medical and behavioral chronic and acute conditions in collaboration with specialty providers and team members
Collaborate with PCPs, Emergency Department (ED)s, Hospitalists, Discharge Planners and other allied care providers
Coordinates and authorizes all skilled and ancillary services, including Durable Medical Equipment (DME) and supplies
Works in collaboration with the PCP, providers and discharge planners to facilitate proper care and timely discharge to an appropriate setting
Facilitates and/or participates in member care conferences and educational meetings
Establishes and maintains an ongoing working relationship with providers and other appropriate community resources/agencies
Facilitates staff, member and family decision making by providing educational tools
Serves as the key contact and central coordinator of the health care team
Documents member encounters, medical records, updates the EMR within established timeframes
Documents plans, communications, rationales for plan changes and collaborative discussions
Collaborates with Neighborhood staff in support of organizational objectives
Other duties as assigned
Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.
Qualifications
Qualifications
Required:
Advanced Practice Registered Nurse (APRN) Licensure active license in state of Rhode Island
Graduate of an accredited Nurse Practitioner (NP) Program
Proven skills and knowledge base necessary for independent clinical decision making
Demonstrated competency and experience delivering primary care to adults in underserved populations
A high comfort level in providing care in the members home
Strong organizational and documentation skills
Strong problem solving skills and attention to detail
Effective oral and written communication skills
Intermediate skills in Microsoft Office (Word, Excel, Outlook) including electronic medical records (EMR)
Dependability when necessary, commits to hours necessary to meet the needs of members
Time flexibility - Must be willing to work nights and/or weekends when member needs arise
Must have access to reliable transportation. If using personal vehicle, must have valid, active drivers license and current auto insurance
Requires 24/7 telephonic on-call service and periodic on call for home visits must be able to respond to calls within 1-2 hours
Compliant with State of RI immunization regulations for health care workers
Preferred:
Bilingual
Nurse Practitioner clinical experience
Medicare/Medicaid experience
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
Corporate Accounting Student Intern - Summer 2025
Providence, RI Job
Please email HR_Talent_************************** if you are a candidate seeking a reasonable accommodation for the application and/or interview process.
Schedule: Hybrid
Compensation: $18-$25 hourly
Jump into the new world of health insurance:
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), our business is healthcare. But our focus is on improving lives. Be part of a team that is large enough to make a difference but small enough to be innovative. Work in a rapidly changing field. Take a chance to be creative. Move outside the status quo. Shape new ideas with the power of a national brand behind you.
Join others who know diversity is strength:
We appreciate and celebrate everything that makes us unique: age, national origin, citizenship status, perspectives, experiences, physical or mental disability, military status, race, ethnicity, religion, gender, sexual orientation, gender identity and/or expression. Our diversity strengthens us as an organization and helps us better serve an increasingly diverse Rhode Island population.
Why this job matters:
The Corporate Accounting team is looking for a student intern to work within our finance department. The student will support day to day functions and assist with special projects.
What you will do:
Help with posting journal entries and other financial transactions into the general ledger system.
Assist in checking account balances to ensure they match the financial statements.
Keep organized files for fixed assets, investments, and other financial documents.
Support the team in preparing financial reports and schedules.
Help maintain the general ledger system by updating data and reports.
Participate in team projects and provide support as needed.
What you need to succeed:
Basic understanding of accounting principles and their application in daily tasks
Familiarity with standard mathematical concepts and their practical use
Ability to analyze numerical data and draw meaningful conclusions
Research skills to identify trends and suggest appropriate actions
Strong attention to detail
Ability to collaborate effectively in a team environment
Good written and verbal communication skills
Sound judgment and decision-making abilities
Proactive in finding solutions to challenges
Ability to build and maintain strong working relationships with various stakeholders
Efficient organization and time management skills to meet deadlines and quality standards
Proficiency with Microsoft Office Suite (Word, Excel, PowerPoint, etc.)
Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:
In-office: onsite 5 days per week
Hybrid: onsite 2-4 days per week
Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national origin, disability, veteran status, sexual orientation, genetic information and gender identity or expression.
The law requires an employer to post notices describing the Federal laws prohibiting job discrimination based on race, color, sex, national origin, religion, age, equal pay, disability, veteran status, sexual orientation, and genetic information and gender identity or expression. Please visit ********************************************* to view the "EEO is the Law" poster.
Other details
Pay Type Hourly
Stars Program Manager (41850)
Neighborhood Health Plan of Rhode Island Job In Smithfield, RI
Under the direction of the Director of Quality Improvement and Grievance and Appeals, the Stars Program Manager supports the Medicare Special Needs Plan (SNP) Stars program. This is through alignment of internal stakeholders and external stakeholders to develop, execute and monitor a comprehensive star strategy for the SNP product line. The Program Manager leads the identification, design and implementation of company-wide quality improvement initiatives through cross-functional work teams in support of Stars performance and to attain the highest-level performance.
Duties and Responsibilities:
Responsibilities include, but are not limited to, the following:
* Establish and lead the operational work plans for the Stars Program including the identification of risks and potential mitigation plan
* Lead the development of Stars related data strategy including the development and implementation of dashboards
* Monitor the Stars performance through ongoing analysis of data and find opportunities for improvement for all measures in the program. Work collaboratively across the organization to ensure gap in performance are addressed
* Conduct ongoing evaluation of initiatives implemented and makes recommendations based on the evaluation
* Use evidence-based and multi-component approaches to program strategy, design, and execution
* Lead cross-functional inter-departmental team which plans, organizes, coordinates and identifies improvement opportunities in support of achievement of highest level of Stars Rating
* Lead efforts in obtaining the highest pay for performance incentive awards in the Stars program, including the identification of potential risks in achieving the highest level of performance
* Collaborate with internal and external stakeholders on provider-based strategies to support Stars performance
* Responsible for assuring that the annual Stars Rating data and the information on performance are analyzed and disseminated to help identify high-priority improvement and innovation opportunities for the organization
* Serve as the subject matter expert on Medicare Stars program including all aspects of the technical specifications
* Maintain strategic relationships and partner with key resources, both internal and external, to support the design and ensure market, member, and provider considerations are factored into the design. May include vendor oversight
* Maintain current knowledge of all present and future quality mandates from regulatory bodies including NCQA, Executive Office of Health and Human Services, Centers for Medicare and Medicaid Services and other regulatory bodies
* Coach, mentor, motivate, and provide oversight to project team members and influence them to take positive action and accountability for their assigned work
* Perform other duties as assigned.
* Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.
Qualifications
Qualifications
Required:
* Bachelor's degree, preferably in business administration, health care administration, public health or related field. In lieu of a degree, previous experience greater than five (5) years managing a Stars program.
* Five (5) or more years' of experience in health care managing a Medicare Stars program with ability to drive performance.
* Knowledge and experience in data collection, technical specifications, and key performance drivers of all Stars measures
* Ability to work with and present results to high level internal and external entities, such as senior leaders, provider groups and state regulatory entities
* Experience leading workgroups, designing quality improvement initiatives
* Strong program/project management, analytical, planning, and goal-setting skills. Including process improvement and change management
* Ability to develop and implement detailed project plans, including handling multiple projects simultaneously in a deadline driven environment
* Experience working with a multi-disciplinary team, multiple collaborators and communicating with all levels of various organizations
* Proven ability to handle various assignments in a fast-paced and complex business environment.
* Strong organizational and documentation skills
* Strong team building, coaching and leadership skills
* Solid time management and organizational skills
* Ability to work autonomously and independently
* Excellent customer service orientation
* Intermediate to Advanced skills in Microsoft Office (Project, Word, Excel, PowerPoint, Outlook)
Preferred:
* Master's degree in business administration, public health or related field
* Knowledge of Risk Adjustment data validation (RADV)
* National Association of Healthcare Quality certification as a Certified Professional in Healthcare Quality/Organizational Excellence (CPHQ/OE) or similar QI training
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
Senior Contract Administrator (36662)
Neighborhood Health Plan of Rhode Island Job In Smithfield, RI
On-site Salary Range (Min. 72K, Mid. 94k) The Senior Contract Administrator is responsible for the end-to-end contracting process including, contract strategy development and negotiation through to execution with an emphasis on complex, high profile negotiations. This position develops, facilitates and implements provider negotiation strategies that support strategic and corporate goals. This position is responsible for the ongoing monitoring and management of contract terms including claims system configuration, contract oversight and adherence to all managed care health plan requirements. Provides support in the absence of a manager.
Duties and Responsibilities:
Responsibilities include, but are not limited to:
* Responsible for complex, high profile negotiations, including the development, proposal and implementation of contractual terms as approved
* Leads negotiations to completion and execute contractual relationships to align with specific corporate and department initiatives, strategic goals and objectives. Responsible for the accuracy of all contract and rate proposals and final contracts. Ensuring reimbursement is accurately defined, communicated and configured while maintaining network adequacy and member access to care standards and all Plan contractual requirements
* Monitoring of contractual requirements through the ongoing management of contract terms including claims system configuration, contract oversight and adherence to all managed care health plan requirements
* Assists in the development of the vision and strategy for the department and assigned functions including the identification, recommendation and recruitment of providers
* Cultivates strong business relationships internally and externally
* Ensures that providers receive appropriate and timely responses
* Identifies and implements medical expense savings opportunities
* Leads and collaborates departmentally and cross-organizationally in the development and planning of provider contracting initiatives and efficient business processes including recommending modifications to policy and procedures, processes, workflows and communication strategies
* Provides assistance and mentorship to the Contract Administrator and support in the absence of the Manager
* Provides reporting to internal and external parties
* Represents the organization in appropriate internal and external committees and meetings and facilitate internal and external meetings, as required
* Serves as the lead subject matter expert ensuring optimal efficiency in area of responsibility
* Understands, proposes and implements various industry standard reimbursement methodologies as approved
* Works collaboratively with provider relations to understand operational issues, providing assistance in the satisfactory resolutions as needed
* Maintains professional growth and development
* Works on special projects and other duties as assigned
* Responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents
Qualifications
Qualifications-
Required:
* Bachelors degree in Health Administration, Business Administration, Public Health or a related field or an equivalent amount of education and experience
* Five (5)+ years experience with a managed care organization or a health care related organization (e.g. HMO, Medicaid, Medicare)
* Three (3)+ years experience with commercial, Medicaid or Medicare contracting and reimbursement
* Three (3)+ years experience with facility, professional, and/or ancillary contracting
* Ability to travel including reliable transportation. If using personal vehicle, must have current, valid drivers license and proof of insurance.
* Intermediate to Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook)
* Demonstrated understanding and experience in contract development, negotiation, financial analysis, data analysis, provider reimbursement mechanisms, contract term implementation and maintenance of contractual terms
* Ability to maintain confidentiality
* Ability to manage data and processes in multiple platforms
* Ability to manage multiple projects simultaneously
* Ability to take direction and function within a team
* Ability to work cross-organizationally to achieve the goals of the company and department
* Demonstrated ability to successfully prioritize and organize own work to meet deadlines
* Demonstrated experience speaking with the provider community, listening to grievances and communicating solutions with good follow-through skills
* Demonstrated understanding of contractual language, health care delivery system, health insurance; insurance laws and regulations, including Medicare and Medicaid policies; claims processing; managed care principals, medical and insurance terminology and procedure and diagnostic codes
* Excellent written and strong business communication and customer service skills (written and verbal) public relations, presentation and facilitation skills. Proven organizational skills and attention to detail
* Knowledge of CMS, Federal and State laws and regulations and other applicable industry standards and benchmarks
* Strong interpersonal skills; builds building high quality relationships internally and externally through actively networking
* Working knowledge of facility reimbursement methodologies including per diem, case rate, bundled payments, and Prospective Payment System (PPS), including Diagnosis-Related Groups (DRG), Ambulatory Payment Classification (APC), Ambulatory Surgery Center (ASC), Resource Utilization Group (RUGs)
* Working knowledge of facility contracting, including hospital, nursing facility, assisted living facility, adult day health care contracting
Preferred:
* Experience in an Accountable Care Organization (ACO)
* Experience in Cognos
* Experience in MedInsight
* Experience in SharePoint
* Knowledge of Quality Improvement Processes (e.g. Lean, Six Sigma)
* Ability to quickly process large amounts of information, connect and integrate data into new solutions or a better understanding of problems, and identify weakness contracts or strategies
* Has ambition that is appropriately displayed through the quality of their work. Individual is driven by a strong internal desire to have impact and influence in the organization
* Experience in delegated entity oversight
Core Company-Wide Competencies:
* Communicate Effectively
* Respect Others & Value Diversity
* Analyze Issues & Solve Problems
* Drive for Customer Success
* Manage Performance, Productivity & Results
* Develop Flexibility & Achieve Change
Job Specific Competencies:
* Plan & Organize
* Build Relationships & Cultivate Networks
* Exercise Sound Judgement & Decision Making
* Collaborate & Foster Teamwork
FDR Oversight:
* N/A
Flexible Work Arrangement:
* Yes as per department policy
Telecommuting Arrangement:
* Yes as per department policy
Travel Expectations:
* Ability to travel including reliable transportation. If using personal vehicle, must have current, valid drivers license and proof of insurance.