Evaluate provider requests for medical necessity across inpatient, outpatient, authorization, retrospective, out-of-network, and treatment-setting reviews, applying clinical criteria, policies, benefits, and contracts. Document decisions, consult Medical Directors when needed, support compliant and timely utilization management, and collaborate with internal teams to promote appropriate care and quality improvement.
The Customer Service Representative provides inbound and outbound support to members and providers, ensuring first call resolution and accurate information delivery. They are responsible for researching claims, documenting interactions, and maintaining compliance with sensitive information requirements.
Engage members to build supportive relationships and conduct holistic health assessments to identify needs and social determinants of health. Develop and monitor member-centric case management plans while coordinating with providers to remove barriers and improve health outcomes.
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.
Case managers engage with members to conduct holistic health assessments and develop personalized care plans that address medical needs and social determinants of health. They facilitate coordination among healthcare providers and use motivational interviewing to support members in achieving their health and lifestyle goals.
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.
Lead a high-performing team of data scientists and AI innovators to develop scalable AI-powered solutions for complex healthcare challenges. Drive the end-to-end ML lifecycle from research and prototyping to production, monitoring, and strategic business alignment.
The Manager of Case Management oversees clinical program operations, strategy implementation, and the continuous improvement of systems to meet business goals. They are responsible for leading, developing, and mentoring a team of clinical and support staff to ensure high-quality performance and regulatory compliance.
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.
