Total 25 job vacancies by NC Health Affiliates LLC DBA Blue Cross NC

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Job Description

What You'll Do

• Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to Plan members.

• Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.

• Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the denial process.

• Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.

• Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements.

• Reviews quality referred issues, focused reviews and recommends corrective actions.

• Develops and implements plan medical policies

• Supports population health

• Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency and continuity of care.

• Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care.

• Ensures that medical protocols and rules of conduct for plan medical personnel are followed.

• Provides clinical expertise in support for quality improvement, sales, account, technology, investment and community engagement activities.

• Works with Contracting Department in contract negotiation.

What You'll Bring (Hiring Requirements):

• MD or DO in Psychiatry from an accredited medical school and completion of a residency training program.

• 10+ years of experience in the related field.

• Current North Carolina medical license and/or Board certification in ABMS/AOA recognized specialty is advanced.

• Occasional weekend work may be required.

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Job Description

About Government Markets at Blue Cross NC 
Government Markets is responsible for sales, retention, market strategy, pricing, and product and segment performance. The division is also responsible for our sales contact centers and retail stores for both the Government Markets and Commercial Markets Divisions.

Our government product segments include Medicare Advantage, Medicare Supplement, the Federal Employee Program, and Healthy Blue (Medicaid).

As a Medicare Sales Consultant, you will be working in the field. In this role, you will work to foster relationships with key community centers of influence, primarily those within the dual-eligible population (those eligible for both Medicare and Medicaid). Internally, you will work with our DSNP and direct sales teams where you will be engaged to provide in-person support for any community events or home visit requests. Throughout the year, this position is tasked with following up with targeted direct mail campaigns through both inbound and outbound calls, as needed.

What You’ll Do

• Responsible for selling Medicare Advantage, Medicare Supplement, and Part D products.

• Educate customers so they can make health care decisions.  Analyze the needs of individual customers and find/recommend products to meet those needs.

• Develop, implement, and present sales strategies to prospects that focus on Blue Cross NC’s key strengths and differentiators to help sell and retain business and maximize membership growth.

• Build and maintain effective relationships with Senior Market customers to meet sales goals.

• Collaborate and negotiate with internal and external partners to find solutions that meet the customer’s needs.

• Maintain current, accurate, and in-depth knowledge of corporate policies, products, benefits, claims, billing, e-commerce tools, service capabilities and overall industry knowledge. 

• Keep abreast of market trends, activities and products of competitors and the economy. 

• Responsible for representing Blue Cross NC’s corporate image to Individuals and stakeholders, anticipating needs and reactions of both. 

• Be articulate in written and verbal communications with prospects and customers, representing Blue Cross NC in a professional manner at all times.

• Support our brand and community teams at events around the state when possible

What You Bring

• Requires a high school diploma and a minimum of 2 years of direct sales or marketing experience; or any combination of education and experience which would provide an equivalent background.

• Must have or be able to obtain a North Carolina Insurance (Accident & Health; Medical Supplement and Long-Term Care) license within the first 60 days of employment in this position.

• Must possess and maintain a valid driver’s license.

Nice to Have

• North Carolina Insurance license (Accident & Health; Medical Supplement and Long-Term Care)

• Experience with the dual-eligible population; Medicare and Medicaid

• Strong relationship building skills

If you’re ready to make a career out of making a difference, this is the opportunity for you. 

We invite you to check out our careers site to see we value diversity and inclusion at all levels of our organization. We have inclusion challenges throughout the year and affinity groups that are an integral part of our culture! 

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Job Description

• Manages day-to-day business area activities, provides leadership, coaching and training to team members, sets clear goals and expectations and manages performance as needed. 
• Creates a positive work environment that fosters teamwork, empowerment, accountability, and superior customer service.
• Acts as a medical and technical resource for team members and other departments, providing assistance/guidance on clinical and/or system issues, benefits, and work processes and procedures specific to departmental needs. 
• Identifies trends, determines root causes, and takes action to resolve issues and initiate necessary process and procedural changes to improve internal and external customer satisfaction.
• Ensures all departmental and clinical reports and necessary reviews are completed in a timely manner. 
• Maintains accountability for achieving targeted results and communicates regularly with organization leadership regarding workloads, issues, projects, monitoring of team performance and staffing needs.
• Leads special projects and/or represents the department on corporate projects that require independent, sound decision making and broad based understanding of effects on the department as a whole. 
• Responsible for the application and compliance with all regulations, standards or other regulatory requirements applicable to departmental operations.  Formulates corrective action plans to address any areas of non-compliance.
• Must maintain current knowledge in applicable clinical areas, standards and certifications (where required) and keep abreast of trends related to the health insurance industry (i.e. CPT, HCPCS, ICD-9, and ICD-10 coding, etc).
• Facilitates meetings and conducts formal presentations for staff and/or cross functional or customer groups as needed.

Hiring Requirements

• RN, PA, FNP or other APN certification. 
• 5+ years of relevant experience.
• Must have valid NC license or multistate compact license.
• Prior experience leading people, projects or programs.
• For some roles, must be Certified Case Manager (CCM) upon hire or within 2 years.

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Job Description

The Communications, Marketing and Corporate Social Responsibility (CMCSR) vision expands the scope of marketing as a shared service for the enterprise and better aligns and integrates our corporate responsibility footprint. We seek to be a world-class Communications, Marketing and CSR team focused on driving results for the business and for our purpose. Serving the company in optimizing new market opportunities, strengthening the Blue Cross NC brand, delivering business value for sustainable growth, and integrating social and philanthropic initiatives into our corporate footprint, this division is laser focused on our purpose of improving the health and well-being of our customers and communities. Our Blue Cross NC Foundation is solely funded by Blue Cross NC and seeks to improve the health and wellbeing of everyone in North Carolina so that our state will be one of the healthiest in the nation, within a generation.  Blue Cross NC and the Blue Cross NC Foundation work together towards these goals. The work this role supports includes CM&CSR and the Blue Cross NC Foundation.

In your role as an Administrative Assistant, Senior Specialist, your primary duties will include the day-to-day support of two high-level executives – providing guidance for executive calendar needs, travel coordination and scheduling, meeting attendance, planning and coordination of events, and managing executive correspondence as needed. You will have an innate willingness to pitch in as needed for events and projects for the CM&CSR team and Foundation to support organizational success; a collaborative mindset to support emerging administrative needs of the division. You will also provide coverage for other Administrative Assistants in the division as needed and work as a team to provide seamless leadership support. On-site opportunities at our Durham campus will range between 6-8 times per year.

What You’ll Do

• Oversee Leader’s workflow including mail, calendar, correspondence, and telephone calls, determining priorities, preparing responses, and/or responding appropriately without errors and in a timely manner.
• Support Leader and other staff by scheduling, planning, and attending meetings as necessary.  Provide support to include expense reporting and travel planning.
• May act as coordinator of departmental projects, following up on pending details, coordinating project team activities and ensuring deadlines are met.
• Exercise considerable discretion and independent judgment and analyzes complex information request and determines complex trends.
• Maintain distribution lists and organizational charts.
• Coordinate activities and events in support of the department.
• Coordinate departmental moves and serve as liaison for IT services and upgrades.
• Assemble and analyze information to facilitate decision making.  Prepare special or one-time reports, summaries, or replies to inquiries, selecting relevant information from a variety of sources such as reports, documents, correspondence, other offices, etc., under general directions.
• Support departmental budget processes which could include running reports, simple budget analysis, and/or budget entries.

What You Bring

• High school diploma or GED
• 5+ years of experience in related field.

What We Like

• Prior experience supporting multiple executives with competing priorities for calendar scheduling
• Knowledge of travel scheduling, both NC-based and out-of-state
• Strong focus on customer service, to provide a high level of service to internal and external stakeholders
• Technical proficiency in Workday and MS Office suite

Additional Locations:

Job Description

This role will report to the Director, Strategy and Growth in Corporate Pharmacy and will lead efforts to develop financial and strategic insights and implementation of the insights to enhance the pharmacy program. The Principal Strategic Advisor, Pharmacy will leverage industry experience and expertise to promote enterprise understanding of pharmacy, oversee strategy and execution, contribute to ‘Response to Trend’ reports and presentations, participate in divisional planning and budgeting, engage in special projects and innovations, and liaise with key vendor partners. The ideal candidate will have experience in the health plan and/or Pharmacy Benefits Manager (PBM) industry, possess consulting and project management skills, and understand payer-PBM operations, pricing, and strategy.

Job Description

·       Proactively identify, evaluate and lead the development of strategic pharmacy projects and Pharmacy Benefit Manager (PBM) partnership efforts to meet BCBSNC’s growth objectives, as well as manage healthcare costs while improving outcomes and the healthcare experience for our members.

·       Lead critical activities such as strategic planning, annual budgeting, highly complex financial/qualitative analysis and thought leadership at a departmental and enterprise level. 

·       Contribute to the development of ‘Response to Trend’ messaging that connects our strategy to trend mitigation.

·       Present information such as strategic concepts, planning data, medical expense/reimbursement rates, drug trend, provider performance metrics and impact assessments to both internal and external audiences at all levels, including senior-level leadership.

·       Organize, optimize and communicate progress towards the completion of overall work portfolio.

·       Collaborate with and support other departments across the enterprise on both common initiatives and unique ventures, acting as a subject matter expert for corporate pharmacy.

·       Identify, analyze and monitor industry, regulatory, technology and market-based trends that affect departmental strategy, PBM landscape, pharmacy trend, and cost of care.

·       Utilize extensive expertise to identify and drive strategy execution with new analysis/reporting capabilities, project management techniques and/or consulting/engagement approaches.

·       Plan, develop, implement and manage multiple/and or large complex programs on an enterprise level.  Coordinate interdepartmental functions in order to minimize delays; work with program/project team members on a regular basis to review deliverables and ensure deadlines are met.

·       Lead strategic planning, needs analysis, content development, program design, implementation, administration and monitoring, data analysis and program evaluation, budget management and vendor selection and vendor/contract management related to strategy execution.

·       Serve as a mentor and coach to more junior team members regarding various skills and approaches and may oversee work of other staff members as needed.

Hiring Requirements

·       Bachelor’s degree with at least 8 years experience with responsibility for strategic/business development, strategic planning, market or product development, healthcare operations, or business process improvement.

·       OR Masters degree with at least 6 years experience as stated above.

·       Direct experience leading and implementing complex business and contractual issues as well as serving as the principal liaison to senior business executives, internal and external, and other outside advisors.

·       Superior communication and collaboration skills to work with various stakeholders, teams, sponsors, members, vendors, senior management, and providers and pharmacists.

·       Significant consultative experience required.

·       Experience related to the management and delivery of programs, projects and work efforts in a portfolio-based environment.

·       The ideal candidate will have extensive experience with payers and PBMs.

In lieu of degree, 10+ years of experience in related field.

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Job Description

What You Will Do

• Maintain reports, dashboards, and KPIs. Design and develop new dashboards if/when necessary.
• Support the cloud budget and monthly forecast process, collaborating with cross-functional teams.
• Monitor cloud consumption, detect cost anomalies, perform root cause analysis, and escalate anomalies to top management.
• Analyze and report cloud consumption across multiple cloud platforms and multiple Business Units and produce meaningful insights from Cloud usage monitoring tools.
• Provide financial analysis and guidance to calculate Unit Economics.
• Assist and collaborate with cross-functional teams on understanding their cloud spend and achieving their FinOps objectives.
• Assist in creating training material and conduct training on Cloud FinOps for various teams.

What You Bring

• 5+ years' experience as an AWS and/or Azure Cloud Engineer (both is a plus)
• 2+ years’ experience doing financial forecasting, optimization and operations specific to Cloud

Additional Locations:

Job Description

What You Will Do

Responsible for Analysis and Functional Design:

• Quickly understand business issues and data challenges of the customer. Critically evaluate information gathered from multiple sources, reconcile conflicts, and decompose high-level information into details; abstract up from low-level information to a general understanding. 
• Consider end to end business and technical flows, including impacts to operations.
• Review, edit, and prioritize business requirements, specifications, processes and recommendations related to proposed solution. Distinguish user requests from the underlying true business need.
• Translate business/functional requirements into system level functional solutions using various techniques that include: interviews, document analysis, requirements workshops, surveys, site visits, business process descriptions, use cases, screen interface prototypes, demos, and/or business, task, and workflow analysis.
• Develop functional design specifications, GUI and screen interface designs (internal applications), and VUI designs for customer engagements. Include project assumptions, risks/issues, considerations, and dependencies based on the system impacts. Identify the business process and organizational impact of proposed solutions.

Responsible for Technical Recommendations and Traceability:

• Partner with project personnel to identify required system changes, additions or retirement. Conduct gap analysis for business/functional requirements and current system functionality, with support, review and input from other Technical staff.
• Collaborate with business analysts, designers, developers and subject matter experts to establish the technical vision and analyze tradeoffs between usability and performance needs. Help to divide the project into multiple phases based on the business priorities, design, schedule, and level of effort.
• Ensure traceability from business/functional requirements through development of the solution, to confirm system functionality and ensure the completed system fulfills the goals of the project as detailed in the specifications.

What You Bring

• Bachelor's degree or advanced degree (where required)
• 3+ years of experience in related field.
• In lieu of degree, 5+ years of experience in related field.
• Experience with REST or SOAP services.

Additional Locations:

Job Description

What You Will Do

• Support day-to-day development of multiple strategic initiatives at once, including managing timelines, potential risks, and final deliverables with limited input from executive leadership.

• Responsible for conducting high level business analysis involving complex requirements, problem resolution, development of member fulfilment outputs such as Summary Plan Description (SPD), Summary of Material Modifications (SMM), Summary of Benefits and Coverage (SBC), Custom Benefit Grids, Benefit Booklets, etc.

• Provide direct support and input with any Compliance and Regulatory issues or changes in collaboration with internal compliance teams.

• Ability to display knowledge of ASO Custom Benefit Grids, Summary Plan Description (SPD) and ERISA guidelines.

• Crosswalk RFP responses and client ASA language (Blue Third Party Administrator contracts) to client implementation documentation to ensure full scope of services and client expectations accurately reflected.

• Provide support to senior team members on at least one business project team and non-project related activities for the department/division/segment as needed.

• Provide a strategic mindset with a structured approach to problem solving, motivated by intellectual curiosity.

What You Bring

• Bachelor's degree or advanced degree (where required)

• 3+ years of experience in related field

• In lieu of degree, 5+ years of experience in related field

• NC Life and Health Insurance License (or be able to obtain it within 90 days of employment)

Nice to Have (preferred qualifications)

• Familiarity with CMS/regulatory/BCBSA mandates and IPP Compliance

• Basic project management and decision-making skills

• Time management, presentation, organizational, and customer service skills

• Effective communication skills, including verbal, written, and active listening

• Effective and productive with remedial tasks; capable with direction to address more complex tasks

• Ability to assimilate factual data pursuant to formulating a conclusion

Additional Locations:

Job Description

Additional Locations:

Job Description

What You'll Do

• Manages day-to-day business area activities, provides leadership, coaching and training to team members, sets clear goals and expectations and manages performance as needed. 
• Creates a positive work environment that fosters teamwork, empowerment, accountability, and superior customer service.
• Acts as a medical and technical resource for team members and other departments, providing assistance/guidance on clinical and/or system issues, benefits, and work processes and procedures specific to departmental needs. 
• Identifies trends, determines root causes, and takes action to resolve issues and initiate necessary process and procedural changes to improve internal and external customer satisfaction.
• Ensures all departmental and clinical reports and necessary reviews are completed in a timely manner. 
• Maintains accountability for achieving targeted results and communicates regularly with organization leadership regarding workloads, issues, projects, monitoring of team performance and staffing needs.
• Leads special projects and/or represents the department on corporate projects that require independent, sound decision making and broad based understanding of effects on the department as a whole. 
• Responsible for the application and compliance with all regulations, standards or other regulatory requirements applicable to departmental operations.  Formulates corrective action plans to address any areas of non-compliance.
• Must maintain current knowledge in applicable clinical areas, standards and certifications (where required) and keep abreast of trends related to the health insurance industry (i.e. CPT, HCPCS, ICD-9, and ICD-10 coding, etc).
• Facilitates meetings and conducts formal presentations for staff and/or cross functional or customer groups as needed.

What You'll Bring (Hiring Requirements)

• RN, PA, FNP or other APN certification.  For Behavioral Health specific roles, other applicable licensure will be considered (LMSW, LCSW, LPC, LMFT, etc).
• 5+ years of relevant experience.
• Must have valid NC license or multistate compact license.
• Prior experience leading people, projects or programs.
• For some roles, must be Certified Case Manager (CCM) upon hire or within 2 years.

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Additional Locations:

Job Description

IT is different here. Our work as technology specialists pushes the boundaries of what’s possible in health care. You will build solutions that make a real difference in people’s lives. Driven by the importance of their work, our team members innovate to elevate. We’re encouraged to be curious, collaborate, and turn ideas into solutions that can make health care better for all.

If you are ready to make a career out of making a difference, then you are the person for this team.

As a Principal Cloud Architect you are expected to perform the following duties:

• Serve as the lead architect on cloud initiatives. This involves planning developing, maintaining, and reviewing cloud architecture throughout the project.
• Collaborate with project teams (business stakeholders, peer architecture disciplines, development/delivery teams, vendors, test/QA).
• Lead the cloud migration efforts
• Develop and maintain Cloud Architecture models, specifications, and other documentation (key written project deliverable) and/or oversee and approve such architecture documentation.
• Lead Proofs Of Concepts (POCs) leading to deployment of applications and infrastructures in the cloud.
• Depending on the specific role, design infrastructure solutions involving cloud infrastructure.
• Ensure solution deliveries are accurately and thoroughly reviewed as per applicable standards.
• Participate in and/or lead cross-functional IT Architecture groups that review designs from an enterprise perspective.
• Drive adherence to existing and evolving security requirements to ensure a robust and secure cloud environment.
• Drive adherence to application and technology standards and patterns, application portfolio strategy, and service level agreements.
• Partner with other project leaderships to identify and mitigate technical risks, assumptions, issues, and dependencies related to cloud architecture
• Influence and drive improvements to cloud architecture processes, strategies, and standards.
• Support pre-project efforts in terms of working with the user, IT delivery, and vendor teams, crafting conceptual solutions, and assisting with delivery time estimates.
• Provide technical expertise/coaching for others. 
• Monitor architecture related to other areas of IT, business communities, and vendors to ensure the relevance of architecture to meet business needs.
• Provide cloud architectural leadership that supports insightful decision making, drives efficiencies in the development process, and maximizes the quality of technical deliverables.
• Create or review IT plans that manage clear and realistic expectations of what technology can offer in terms of products, services, and delivery mechanisms.
• Establish, maintain, and review enterprise models of the cloud architecture to enable applications development and decision-supporting activities, consistent with IT plans.
• Provide technical expertise/coaching for others. Support and mentor less experienced staff.

What You Bring

• Bachelor’s Degree and 10 years of progressive experience in a combination of development, design in areas of cloud computing
• If no degree, 12 years of progressive experience as stated above
• Must have served for at least 5 years as a thought leader in cloud practice in Cloud Service Providers like AWS and/or Azure
• Must have 5 years of experience in leading migration to the cloud, cloud practice, and cloud native architectures in AWS and/or Azure
• Must have a solid understanding of Continuous Development and Deployment in AWS or Azure
• Must have at least 7 years of direct infrastructure, system, application and cloud architecture experience driving comprehensive end-to-end solutions involving AWS or Azure.
• Must have certifications in popular cloud providers like AWS or Azure
• Must be proficient in designing and maintaining cloud-based infrastructures in AWS or Azure to deliver the required performance, security, and availability requirements
• At least 5-7 years’ experience in AWS or Azure Platform as a Service (PaaS) and Infrastructure as a Service (IaaS)
• Must haven solid hands-on experience in technologies like EC2, Lambda, S3, RDS, VPC, IAM, Cloud Watch
• Must have certifications in popular cloud providers like AWS and/or Azure Preferences

Experience in multiple architecture disciplines is preferred. Some experience formally leading technical teams is preferred. Prefer candidates with knowledge and understanding of: Regulatory and legislative impact on health plans, specifically security requirements driven by HIPAA; Health insurance and plan administration. Experience in middleware technologies like Kafka, JBOSS and WebSphere Experience and knowledge of cloud native architectures such as Kubernetes, OpenShift, and DevSecOps. Strong leadership and mentoring skills, including team leadership and work organization/coordination. Excellent influencing and consultative skills; and the ability to proactively identify and resolve issues and opportunities. Experience working closely with the business, IT personnel and other architectural areas to provide research and development around application trends, integration patterns, vendor direction and development methodologies. Understand business behavior patterns and patterns of information and technology and how they work together to enable the business to achieve their strategic and tactical goals. Prefer a certification in at least one facet of IT architecture.

Additional Locations:

Job Description

What You Will Do

Responsible for Analysis and Functional Design:

• Quickly understand business issues and data challenges of the customer. Critically evaluate information gathered from multiple sources, reconcile conflicts, and decompose high-level information into details; abstract up from low-level information to a general understanding. 
• Consider end to end business and technical flows, including impacts to operations.
• Review, edit, and prioritize business requirements, specifications, processes and recommendations related to proposed solution. Distinguish user requests from the underlying true business need.
• Translate business/functional requirements into system level functional solutions using various techniques that include: interviews, document analysis, requirements workshops, surveys, site visits, business process descriptions, use cases, screen interface prototypes, demos, and/or business, task, and workflow analysis.
• Develop functional design specifications, GUI and screen interface designs (internal applications), and VUI designs for customer engagements. Include project assumptions, risks/issues, considerations, and dependencies based on the system impacts. Identify the business process and organizational impact of proposed solutions.

Responsible for Technical Recommendations and Traceability:

• Partner with project personnel to identify required system changes, additions or retirement. Conduct gap analysis for business/functional requirements and current system functionality, with support, review and input from other Technical staff.
• Collaborate with business analysts, designers, developers and subject matter experts to establish the technical vision and analyze tradeoffs between usability and performance needs. Help to divide the project into multiple phases based on the business priorities, design, schedule, and level of effort.
• Ensure traceability from business/functional requirements through development of the solution, to confirm system functionality and ensure the completed system fulfills the goals of the project as detailed in the specifications.

What You Bring

• Bachelor's degree or advanced degree (where required)

• 3+ years of experience in related field.

• In lieu of degree, 5+ years of experience in related field.

Additional Locations:

Job Description

​What You'll Do

• Improve quality of care for our members through leadership of quality improvement strategy development, program implementation and ongoing oversight for all Commercial products (i.e. Marketplace/ACA).
• Responsible for FEP quality programs; lead and coordinate efforts to achieve quality program goals and maximize incentive performance for our organization.
• Engage matrixed teams across the organization to drive progress to QI goals (i.e. Health Plan Product Ratings, CAHPS) by leveraging expertise in related requirements. Develop roadmap to define specific actions to improved quality performance.  
• Works with Enterprise on developing and implementing HEDIS member engagement strategies.
• Works with leadership to provide information or data as requested.
• Facilitates and  coordinates the implementation and evaluation of identified quality improvement / HEDIS activities as requested.
• Promotes understanding, communication and coordination of all quality improvement program components.
• Coordinates reporting on quality initiatives to all appropriate committees.
• Assists with the development of the QM and UM Work Plan, Evaluation and the monitoring of Work Plan activities as they relate to PI.
• Maintains current knowledge of regulatory requirements associated with the QI program.  
• Utilize expertise in QM/QI theory and methodologies to build quality programs driven to member centric outcomes measurement.
• Use data and other insights to identify effective solutions for improving Commercial product quality performance, leveraging health plan historical performance and industry knowledge.
• Ensure ongoing monitoring and evaluation of programs and interventions to determine impact and ROI. Develop remediation strategies as needed. 
• Keep abreast of industry trends, both national and local, and synthesize such information to proactively identify ways to improve quality of care while concurrently ensuring all applicable accreditation and/or regulatory standards are met.
• Partner with provider network and engagement teams to drive quality improvements that positively impact patient care; provide oversight of quality performance measurement in support of these efforts.
• Oversee vendor relationships for applicable quality programs.
• Present results of improvement efforts and ongoing performance measures to senior leadership.

What You'll Bring

• Bachelor’s degree or advanced degree (nursing, social work, health care management, public health or other related field)
• 8+ years of experience in related field (quality management, healthcare operations management, clinical project/program management and/or clinical data management)
• In lieu of degree, 10+ years of experience in related field
• Knowledge of NCQA, HEDIS and CAHPS

Nice to Have

• Experience with HEDIS related data
• Experience leading teams and/or directly managing staff

Additional Locations:

Job Description

• Manage/administer smaller Medicare programs or a phase of a larger Medicare program to ensure that prescribed activities are carried out in accordance with program objectives for the Corporate Pharmacy Department.
• Assess needs and coordinate resources to enhance existing Medicare programs.
• Monitor the progress of Medicare program components to ensure the overall goals, schedules, and benefits of the program will be met.
• Document and present Medicare program results through operational reports, outcomes studies, presentations and publications.  Prepare program reports for superiors.
• Recommend and/or implement Medicare program and process changes as needed to achieve program goals and objectives.
• Control expenditures in accordance with budget allocations, together with the conformance to timing, limits and usage of funding as agreed upon in the spending plan for the assigned program, if applicable.
• Participate in vendor management and administer Medicare program contracts to ensure vendors meet service level agreements, if applicable.

Hiring Requirements

• Bachelor's degree or advanced degree (where required)

• 3+ years of experience in related field

• In lieu of degree, 5+ years of experience in related field

• Knowledge of, and expertise in, Medicare pharmacy and medical benefits, including CMS regulations

• Proficient with use of Microsoft Word, Excel, and PowerPoint

• Prefer candidates with strong skill sets in the following areas: attention to details, time management, adaptability, independent contributor

Additional Locations:

Job Description

• Manage day-to-day relationship between business and vendor(s) to ensure seamless and effective delivery of outsourced services.

• Primary communicator/liaison between vendor and business stakeholders to answer questions, provide performance metrics updates, manage capacity and demand, and remediate escalations as needed. 

• Facilitate vendor onboarding process through effective communications and training to educate the vendor on processes and operational details and successfully transition business processes and/or operations to operational business teams.

• Partner with business leads to understand evolving service needs and expectations, define business requirements, and work with the vendor to improve capabilities.

• Establish and coordinate ongoing service level metric/performance reporting to monitor vendor performance and ensure contractual obligations and/or other performance agreements are met. 

• Analyzes information to determine if there are gaps in performance and how to best address through process improvements, training and/or other interventions. 

• Define internal process for handling high severity and stagnant issues/events; escalate and partner with internal business partner for remediation as needed.

• Ensure adherence to standard procedures for vendor governance, including data access and security.

• Review vendor's work with business teams for quality issues, design and administer customer surveys and other feedback processes and lead formal vendor service reviews and/or audits as needed.

• Provides inputs to vendor contract negotiations to ensure vendor contracts align to business strategy.

• Collaborate with internal business partners on vendor strategy discussions, providing data, knowledge and feedback on vendor operations from the business perspective.

Hiring Requirements

• Bachelor's degree or advanced degree (where required)

• 3+ years of experience in related field.

• In lieu of degree, 5+ years of experience in related field.

Preferred Experience:

• Vendor Management experience in a Healthcare related organization.

• Healthcare contracting experience / PBM experience.

• Knowledge of KPI/SLA and performance metric analysis.

• Detail oriented.

• Ability to effectively multi-task high priority work.

• Ability to work in a fast-paced environment.

• Ability to deliver in a timely manner with accuracy.

• Lean Methodology knowledge, a plus.