Identifies, analyzes, and determines medical necessity, pre existing conditions, benefit eligibility and/or individual consideration reimbursement allowances for novel and complex medical management related claims, using varied and broad clinical expertise. The Medical Review Analyst acts as a member advocate to promote and coordinate the delivery of quality, cost effecti

The incumbent will use clinical and coding expertise to analyze medical records and charts in relation to provider coding. The Coding Analyst identifies physician practices with complex coding patterns and reports relevant data to the Centers for Medicare and Medicaid Services (CMS). What You'll Do Analyzes necessary documentation, including medical records/charts, and ap

The Blue Cross NC Diversified Business Group (DBG) is focused on driving improvements in health care, affordability, access and equity through investments and partnerships with innovative health care organizations in North Carolina and beyond. We have a history of forging forward thinking partnerships and investments with like minded partners to create the blueprint of th

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is seeking a Strategic Advisor to join our growing Care Delivery Services Team! We are looking for a driven and entrepreneurial individual that is excited by a role that involves executing a strategic vision for the company. You are the art of the possible, able to successfully support projects related to high v

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 fo

Leads and manages the day to day operational and tactical aspects of all Commercial related Pharmacy Benefit Management (PBM) activities, new initiatives, and other ongoing business deliverables in accordance with business needs. Identifies, evaluates, and resolves issues that conflict with PBM related deliverables. Collaborates closely with project team members, business

Under general guidance and supervision, applies knowledge of mathematics, probability, statistics, and principles of business in order to provide assistance and technical support for rating/pricing, valuation, healthcare economics and/or financial forecasting. Works with a team of actuaries to assure a coordinated approach to the actuarial components of health programs. P

Responsible for providing analytic support, which includes data collection, trending, reporting and forecasting functions to ensure data integrity. Will design, develop, analyze and determine reporting controls and procedures for the department and/or internal clients. What You'll Do Provide programming support to extract and analyze data from different enterprise systems

Lead cross functional IT Architecture groups that develop solution strategies and review designs from an enterprise perspective. 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 in

Utilizing strong functional/technical area knowledge and expertise with relevant systems/applications. The incumbent defines, evaluates, and validates requirements, business functional design, and technical design for complex business issues within their domain areas. They act as a liaison representing their department and the processes and workings within it to develop e

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 fo

Corporate Pharmacy spearheads Blue Cross NC's prescription drug initiatives through member focused formulary design, sales team support, benefit plan creation, program development, and more. This department collaborates on innovative solutions with its pharmacy benefit manager Prime Therapeutics (Prime) and other strategic partners to deliver significant value through imp

As an Enterprise Strategy Senior Consultant, you'll develop new and groundbreaking strategies to further our purpose to make health care better for all by solving complex challenges that transform health care and have a real impact on the lives of our customers and communities. The Enterprise Consulting team leads at the intersection of health care and strategy to deliver

Blue Cross NC Corporate Pharmacy Department is seeking an Associate Vice President (AVP) for Government Pharmacy. The role involves leading teams in the Medicare Segment with plans for expansion into other Government Segments. The ideal candidate will have demonstrated experience in team leadership, product development, Utilization Management, Cost of Care, and quality st

This is a provider facing role. Evaluates and monitors provider performance to achieve excellence in risk adjustment coding. Participates in regular provider meetings and/or calls with other internal BCNC teams for collaboration on Blue Premier success. Provides timely, relevant, accurate, and objective feedback to providers, and the management team which includes a plan