Utilization Management Director - Inpatient (Hybrid) Blue Cross and Blue Shield AssociationUtilization Management Director - Inpatient (Hybrid)Baltimore, MD$135,040–$250,668 / yearPURPOSE: The Director Utilization Management (Inpatient) provides strategic leadership of the inpatient utilization management team and is responsible for the design, assessment, implementation and outcomes of inpatient utilization management strategies using a multidisciplinary approach to enhance member engagement, improve access to quality care and the use of cost-effective health resources. Plans, directs and evaluates the full scope of utilization management services offered in collaboration with the preservice UM Director, and works closely with leadership, members, providers, vendors, accounts, and other strategic business partners.
Clinical Appeals Nurse (Remote) Blue Cross and Blue Shield AssociationClinical Appeals Nurse (Remote)DCRemote$67,320–$133,705 / yearESSENTIAL FUNCTIONS: Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stake holders and any other initiators. Investigates, interprets, analyzes and prioritizes appeal requests using nursing expert knowledge and all available clinical information for both medical and behavioral health conditions, as well as medical policies, to determine if the adverse coverage and adverse decisions are appropriate.
Clinical Support Supervisor (Hybrid) Blue Cross and Blue Shield AssociationClinical Support Supervisor (Hybrid)Baltimore, MD$62,280–$128,453 / yearCollaborates with members and/or family members, health care providers, community resource partners, and internal clincial and non-clinical colleagues to ensure effective service delivery and integration of member focused activities whether in Care Management, Utilization Review and/or Appeals functional areas. Maintains and improves clinical support operations by monitoring departmental and system performance; identifying and resolving problems; supervising process improvement and quality assurance programs; and supervises the process of conducting and following up on internal or external audits.
Supervisor, Provider Disputes Blue Cross and Blue Shield AssociationSupervisor, Provider DisputesBaton Rouge, LAPursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner. Necessary Contacts: In order to effectively fulfill this position, this position must be in contact with: Various internal and external entities including, but not limited to, all levels of BCBSLA personnel, attorneys, group leaders, members, hospitals, physician offices, and DOI.
Health Plan Pharmacist Blue Cross and Blue Shield AssociationHealth Plan PharmacistCheyenne, WYIn addition to the minimum requirements, we prefer candidates who possess Post-graduate PGY1 managed care pharmacy residency accredited by AMCP, ASHP; Masters of Healthcare Administration; Masters of Business Administration; work experience with health insurance payor; and/or work experience with a PBM. You will deal with long term strategies, high-level company initiatives, and day-to-day operations - overseeing functions including (but not limited to) Group benefits consultation, formulary management, drug cost evaluations, network management, and pharmacy operations.
Chief Financial Officer (Cfo) Blue Cross and Blue Shield AssociationChief Financial Officer (Cfo)Cheyenne, WYMedical Economics, Reserves & Actuarial Partnership: Partner with the plan's actuary (in-house or consulting) on premium rate development, rate filings, and financial advocacy with the Wyoming Department of Insurance and CMS, ensure the adequacy and integrity of claims liabilities, including incurred-but-not-reported (IBNR) reserves and premium deficiency reserves, with appropriate documentation and independent review, owns the financial management of medical loss ratio (MLR) and medical cost trend; work with clinical, network, and operations colleagues to manage medical expense and improve forecast accuracy, oversees risk-adjustment revenue integrity, including encounters submission and reconciliation and risk-score accuracy, and monitor minimum-MLR rebate exposure under program requirements, and proactively engages with actuarial team members to analyze complex data patterns, align predictive models with long-term corporate goals, as well as facilitate unified financial insights. Accounting, Controls & Financial Reporting: Oversees the accounting function and the timely, accurate monthly close under both U.S. GAAP and statutory accounting principles (SAP) as promulgated by the NAIC, directs the preparation and filing of statutory financial statements (the NAIC Annual and Quarterly "Orange Book" filings) with the Wyoming Department of Insurance, along with the organization's IRS Form 1120 and other required financial filings with CMS, maintains a strong internal control environment appropriate to the plan's size, and coordinate the external financial, statutory, and single (Uniform Guidance) audits as applicable, serving as the primary liaison to the Board's Finance & Audit Committee.
Manager, Hedis Operations Blue Cross and Blue Shield AssociationManager, Hedis OperationsCheyenne, WYDepending on the department and the position, eligible employees may be offered limited In-Office/WFH flexibility (for those positions that are offered limited WFH, there will be a required number of In-Office days per week/month depending on department). You will work with intra-agency teams, vendors, executive leadership and others to build and administer a comprehensive quality program providing the best possible care for our members.
Supervisor, Provider Disputes Blue Cross and Blue Shield AssociationSupervisor, Provider DisputesBaton Rouge, LAPursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner. Necessary Contacts: In order to effectively fulfill this position, this position must be in contact with: Various internal and external entities including, but not limited to, all levels of BCBSLA personnel, attorneys, group leaders, members, hospitals, physician offices, and DOI.
Government Programs Compliance Lead Blue Cross and Blue Shield AssociationGovernment Programs Compliance LeadChicago, IllinoisActing as a primary liaison to operational teams, the position translates complex regulatory requirements into practical, embedded business processes, ensures compliance integration into day-to-day activities, and provides expert guidance across core functional areas such as claims, pharmacy, utilization management, and appeals, with a strong emphasis on enterprise risk assessment and regulatory alignment. Ability to interpret and apply regulatory requirements to complex business scenarios and provide practical, risk-based compliance guidance to operational stakeholders Strong governance and reporting skills including experience supporting compliance committees, senior leadership reporting, and Board-level oversight.
Provider Credentialing Specialist I (Remote) - Dental Blue Cross and Blue Shield AssociationProvider Credentialing Specialist I (Remote) - DentalDCRemote$38,520–$70,620 / yearMaintains the provider file, the Provider Information Control (PICS) inventory workflow system and electronic provider files with updated provider information during processes, such as credentialing, recredentialing, demographic updates, terminations and all other provider file maintenance activities. Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
Quality Specialist (Hybrid) Blue Cross and Blue Shield AssociationQuality Specialist (Hybrid)Baltimore, MD$48,168–$95,667 / yearQUALIFICATIONS: Education Level: Bachelor''s Degree in Population Health, Public Health, Healthcare Administration, Business Administration, Health Policy, Economics, Statistics, Mathematics, Data Science, or a related field OR in lieu of a Bachelor''s degree, an additional 4 years of relevant work experience is required in addition to the required work experience. PURPOSE: Utilizing the population health frameworks provided by NCQA Accreditation, HEDIS and CMS, this position is responsible for delivering culturally appropriate health promotion information to members that helps increase their access & reduce their barriers to preventive care resulting in industry-leading outcomes at a population level.
Senior Data Analyst - ACA Risk Adjustment (Hybrid) Blue Cross and Blue Shield AssociationSenior Data Analyst - ACA Risk Adjustment (Hybrid)Baltimore, MD$87,264–$173,316 / yearQUALIFICATIONS: Education Level: Bachelor''s Degree in Data Science, Mathematics, Computer Science, Statistics, Business or related field OR in lieu of a Bachelor''s degree, an additional 4 years of relevant work experience is required in addition to the required work experience. Understand the impact of the HCCs on the risk adjustment revenue including interpretation of CMS guidelines, monitoring and determining the impact of any changes to the HCC model and supporting actuarial in the calculation risk adjustment revenue.
Supervisor, Medicare Advantage Enrollment & Billing Blue Cross and Blue Shield AssociationSupervisor, Medicare Advantage Enrollment & BillingMonroe, LANecessary Contacts: In order to effectively fulfill this position, the incumbent must be in contact with: Various internal departments including but not limited to: Account Managers/Executives, Accounting, Actuarial, BET, Claims Units, Claims Systems Development Specialists, Corporate Compliance, Customer Services, Executive Management, Installation Managers, IT, Legal, Marketing (including Regional Directors), Plan Performance, Provider and Benefits Specialists, Provider Contracts, Provider Reimbursement System Audit Specialists, Quality Management, Underwriting, and other Enrollment and Billing units and other departments within BCBSLA as needed. The Supervisor in the Enrollment and Billing department is responsible for the end to end process for their assigned team including organizing workflow, ensuring that employees understand their duties or delegated tasks, monitoring employee productivity and providing constructive feedback and coaching.
Buildings & Grounds Custodian Blue Cross and Blue Shield AssociationBuildings & Grounds CustodianCheyenne, WYDepending on the department and the position, eligible employees may be offered limited In-Office/WFH flexibility (for those positions that are offered limited WFH, there will be a required number of In-Office days per week/month depending on department). As a Building and Grounds Custodian with the BCBSWY Building and Grounds Team, you will play an essential role in ensuring best-in-class appearance of our facilities to members, employees, and members of the general public.
Controller Blue Cross and Blue Shield AssociationControllerCheyenne, WYTo serve effectively in the role, the incumbent will have and maintain contemporary knowledge for a strong accounting background in both GAAP and Statutory accounting and invest in ongoing professional development to achieve excellence in operational finance execution, budget oversight, and the ability to connect finance insights to real-world business drivers. Accountabilities include developing effective strategies, staying on top of regulatory changes, providing relevant information to senior leadership for sound decision making, and collaborating with internal and external stakeholders to provide the best possible outcomes while balancing costs and risks associated with the insurance industry.
Payment Integrity Financial Specialist Blue Cross and Blue Shield AssociationPayment Integrity Financial SpecialistBaton Rouge, LAThis role ensures the accuracy of program payments, billings, vendor financial activity, and cost containment initiatives while delivering actionable insights that improve operational performance, financial outcomes, and regulatory compliance. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.
Medicare Plan Management Principal Blue Cross and Blue Shield AssociationMedicare Plan Management PrincipalChicago, WashingtonServe as the primary relationship owner between BCBSA and the Plans for the national Medicare Advantage program by liaising with Plan contacts, ensuring satisfaction, aligning business processes with strategic goals, overseeing strategy sessions, policy development, and performance metrics, approving budget activities, updating stakeholders, coordinating support teams, and assessing technological efficiencies. This leadership role serves as the primary architect of how BCBSA engages, educates, and activates BCBS Plans participating in the national MA program — translating national program strategy into actionable, plan-level initiatives that drive adoption, performance improvement, and sustained operational alignment.
Accreditation Program Specialist Blue Cross and Blue Shield AssociationAccreditation Program SpecialistChicago, WashingtonThis role is responsible for leading multiple cross-functional projects, services and associated deliverables related to Federal Employee Program (FEP) and local Blue Plans Heath Plan Accreditation, the Accreditation Town Hall call, as well as other initiatives. A candidate’s position within the hiring range may be based on several factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, shift, travel requirements, and business or organizational needs.
Associate Actuary Blue Cross and Blue Shield AssociationAssociate ActuaryBaton Rouge, LACommunicates pricing changes to Underwriting, Marketing, Information Technology and Actuarial Systems departments and oversees testing of systems output to ensure that the correct price is implemented for each member and that benefit options are accurately quoted. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.
Senior Manager, Internal Audit Blue Cross and Blue Shield AssociationSenior Manager, Internal AuditChicago, IllinoisThe role supports the leader with Internal Audit Department administrative oversight, strategic improvement initiatives (including the evaluation and deployment of artificial intelligence and other automated audit tools and techniques), executive presentations, Plan-facing audit conferences and roundtables, and special projects. Expert knowledge of operational audit disciplines including risk assessments, financial, compliance, and operational process audits; third-party risk/vendor audits; program management audits; and new process/system implementation audits.