The Compliance Specialist develops and monitors the Compliance Program to ensure adherence to regulatory requirements. This includes managing incident reporting, conducting oversight of downstream entities, and responding to compliance inquiries.
Capital Blue Cross
8 Remote Job Openings at Capital Blue Cross
Responsible for the daily and monthly tracking, recording, and balancing of miscellaneous invoices, bank adjustments, and claims payments. The role involves managing corporate compliance for payee affidavits and interfacing financial data into the general ledger.
The analyst develops and administers pricing for healthcare provider contracts and manages the configuration of pricing schedules. They provide analytical support, research reimbursement issues, and coordinate the implementation of professional and facility provider rate changes.
Manage professional interactions with members and providers via telephone, electronic, and face-to-face channels to ensure first-call resolution. Focus on customer retention, quality productivity, and maintaining positive relationships through effective communication and problem-solving.
Supports the Government Programs Division by implementing new products, benefit enhancements, and operational workflows. Oversees the product life cycle from regulatory filings to launch, ensuring compliance with CMS and state requirements.
The Health Navigator coordinates services and addresses barriers to care by collaborating with members, families, and healthcare providers. They provide tools, education, and navigation assistance to help members manage their health and access community resources.
Lead the development of predictive models and analytical frameworks to identify HEDIS performance gaps and prioritize improvement initiatives. Translate complex data into actionable strategic recommendations for executive stakeholders to improve quality outcomes and ROI.
This role leads strategic provider partnerships, including hospitals and physician groups, to negotiate contracts, execute negotiation strategies, and implement innovative reimbursement models like value-based programs. The individual ensures contracts meet regulatory and financial requirements while collaborating across internal teams to support performance programs.
