The specialist manages complex enrollment, eligibility, and billing reconciliation while ensuring compliance with state and federal healthcare regulations. They also provide technical support, conduct performance audits, and collaborate with internal and external partners to improve operational efficiency.
The Membership Specialist II performs complex reconciliation and audit activities for accounts receivable while resolving enrollment and billing discrepancies. They also educate members and partners on contractual guidelines and maintain accurate records to ensure financial and operational compliance.
The Information Analyst III transforms complex data into actionable insights to drive business outcomes and strategic initiatives. They are responsible for designing data reports, developing dashboards, and collaborating with stakeholders to solve complex business challenges.
The Underwriting Manager will lead a high-performing team to manage underwriting, pricing, and contracting activities while ensuring financial objectives are met. They will also serve as a primary point of contact for internal departments and provide strategic support to sales and account management teams.
The consultant supports work transfer readiness, transition planning, and governance activities across operations and vendor partners. They are responsible for coordinating readiness assessments, maintaining documentation, and facilitating stakeholder engagement to ensure successful operational stabilization.
The Customer Service Representative II provides inbound and outbound support to members and providers to ensure first call resolution. They are responsible for researching claims, documenting interactions, and maintaining compliance with sensitive information requirements.
Case managers engage with members to conduct holistic health assessments and develop personalized care plans that address medical and social barriers. They facilitate coordination among healthcare providers and monitor progress to ensure members achieve improved health outcomes and self-care goals.
The Assistant Medical Director performs clinical reviews to determine medical necessity for behavioral health services and acts as a final decision maker for coverage determinations. They also support clinical programs, participate in medical policy development, and engage in peer-to-peer discussions with providers.
The Assistant Medical Director provides benefit coverage determinations based on medical necessity and clinical documentation review. They also support clinical programs and participate in the development of medical review criteria.
Manage a team of clinical coding and payment integrity auditors to ensure accurate claims reimbursement and compliance with regulatory standards. Develop and execute audit strategies, including DRG validation and post-payment initiatives, while leveraging data-driven insights to improve payment accuracy.
The Software Development Engineer IV will lead the design and implementation of complex, enterprise-scale AI and cloud-based solutions. This role involves providing technical leadership, mentoring engineers, and ensuring all deliverables align with architectural standards and business objectives.
The Senior Interplan Consultant acts as a strategic liaison between Premera and various Blue Cross Blue Shield entities to manage renewals, contracts, and operational compliance. This role involves developing growth strategies, negotiating complex healthcare agreements, and ensuring adherence to association requirements.
The Enterprise AI & Data Governance Analyst II will support the organization through AI & Data Governance policy creation, implementation, compliance monitoring, data lifecycle management, and reporting. This role involves collaborating with cross-functional teams to ensure adherence to governance policies and procedures while proactively identifying risks and opportunities.
