Blue Cross NC

Manager

• Coordinate care, resources and/or services for selected member populations
• Provide guidance and promote effective utilization and monitoring of health care resources
• Collaborate with healthcare team members to achieve optimal clinical and resource outcomes
• Perform comprehensive assessments and coordinate with members, families, internal partners, and external providers
• Develop member-centric plans tailored to members’ needs, health status, education, and support needs
• Identify barriers to treatment goals or plans of care
• Utilize community resources and funding sources
• Monitor and manage members through follow-up, education, referrals, documentation, and plan modifications
• Evaluate and facilitate care across the continuum, including physician offices, hospitals, rehabilitation units, skilled nursing facilities, and home care
• Educate members and encourage proactive intervention
• Document assessments, care plans, implementation, monitoring, and outcomes
• Outreach to high-risk, high-cost, or high-utilization members as needed
• Review alternative treatment plans and assess benefits exceptions or flex benefit options as needed
• Evaluate medical necessity and service appropriateness
• Develop policies, procedures, education, or training as needed

Case Manager

Software Engineer

• Design, develop, test, and maintain scalable, high-availability applications supporting mission-critical business operations
• Build maintainable and efficient software solutions across front-end, back-end, and service layers
• Collaborate with cross-functional teams to translate business needs into technical solutions
• Perform analysis, discovery, and technical investigation to identify opportunities, risks, and recommended approaches
• Participate in solution design discussions and contribute to architecture decisions
• Evaluate technology options and recommend build-versus-buy decisions, integrations, and platform capabilities
• Troubleshoot and resolve complex production and development issues
• Promote code quality through testing, code reviews, automation, and development best practices
• Research emerging technologies, industry trends, and engineering practices
• Support application performance, reliability, security, and observability objectives
• Mentor and provide technical guidance to junior developers and team members
• Contribute to agile planning, estimation, and delivery commitments

Senior Developer

Financial Planning and Analysis

• Handle financial claims expense invoicing, reporting, analysis, reimbursement determination, and forecasting
• Prepare weekly invoicing, statements, financial claims expense reports, and month-end closing materials
• Research administrative services and stop loss coverage, including root cause analysis and inquiry resolution
• Analyze claims, plan policies, products, rates, membership, enrollment, underwriting, direct sales, contracts, and program engagement
• Support financial analysis and forecasting for claims expense and stop loss coverage
• Prepare financials for employer groups or stop loss vendors using claims, credits, trends, reports, and other factors
• Review employer group subgroup expenditures for compliance with Administrative Agreements
• Prepare reports, variance analyses, estimates, and adjustments for employer groups, vendors, sales, underwriting, and other audiences
• Verify and identify manual transaction fees and contractual adjustments
• Reconcile statements of account and assist with monthly run-out and final close-out activities
• Compile data for internal and external audits
• Process client transactions including claims holds or suspensions, run-out administrative fees, and employer group settlements
• Determine stop loss benefit eligibility based on contract terms and investigate related vendor inquiries
• Assist with quality reviews of operational inquiries to ensure information accuracy and expected service levels

Client Financial Associate

• Lead and coordinate financial analysis and planning efforts
• Provide divisional leaders with actionable insights, financial discipline, and business outputs
• Identify and prioritize financial strategies
• Create financial plans aligned with company strategic goals
• Develop holistic financial strategies using customer and consumer insights
• Support divisional strategic positions and represent them within the division
• Build and manage internal partner relationships
• Lead annual and long-term financial planning efforts and analyses
• Execute financial and qualitative analyses and thought leadership
• Drive financial innovation and stewardship with internal stakeholders
• Define financial impacts and success measures for initiatives
• Evaluate emerging business ideas and follow through to implementation as necessary

Senior Financial Advisor

• Develop, analyze, interpret, report, and present historical and/or forecasted financial claims expense and stop loss coverage information
• Prepare claims expense financials, estimated claim expense, financial forecasts, and business-related analysis and research
• Coordinate and direct preparation of stop loss coverage for employer groups or stop loss vendors
• Prepare reports and analysis for self-funded groups, stop loss vendors, sales, underwriting, and other audiences
• Perform monthly variance analysis at employer-group or consolidated-company level
• Advise management on financial policy, procedure, application, historical performance, planning, and forecasting
• Review internal and external reports for accuracy, including membership, commissions, and large-claim impacts
• Prepare employer group transactions and statement-of-account reconciliations
• Assist with monthly, run-out, and final closeout activities, schedules, and general accounting functions
• Process client transactions involving suspended or held claims, run-out administrative fees, and employer-group settlements
• Determine stop-loss benefit eligibility based on claimant contract terms
• Serve as a contact for internal and external audits and projects, assisting with planning, testing, training, and implementation
• Perform quality reviews of operational inquiries and communicate results with coaching and training recommendations
• Handle complex eligibility and documentation issues with producers and support underwriting referrals

Client Financial Analyst

Business Analyst

• Provide advanced analytical support for ACA risk adjustment
• Collect data, implement models, perform trending, forecasting, validation, reporting, and financial reconciliation
• Serve as the primary analytical resource for ACA risk adjustment activities
• Prepare and interpret complex data for internal and external customers
• Investigate discrepancies across data sources and systems and translate findings into business insights
• Partner with Actuarial, regulatory submission, value-based program, vendor, and operational stakeholders
• Improve analytical controls, documentation, automation, and recurring processes
• Use SQL, Python, and other approved platforms to access, investigate, validate, and analyze complex healthcare data
• Support ACA risk adjustment model implementation, testing, validation, and recurring member-level RAF score production
• Perform trend, variance, and root-cause analysis
• Reconcile outputs across analytical processes and source systems and coordinate issue resolution
• Manage analytical applications across multiple platforms and coordinate code migrations and environment changes
• Develop analytical processes, controls, reports, and tools
• Optimize report-generation data ingestion, manipulation, profiling, validation, and documentation
• Provide analytical support and problem-solving assistance to business areas
• Make actionable recommendations for financial, operational, regulatory, and strategic decision-making
• Present findings, risks, and recommendations to technical and non-technical audiences, including leadership
• Represent the department on cross-functional project teams and process optimization efforts
• Coordinate analytical support for external vendor engagements and validation activities
• Provide user support for ad hoc reporting, data inquiries, and analytical problem resolution
• Mentor or coach less experienced employees and contribute to cross-training and knowledge continuity

Senior Insights Analyst

Accountant

• Prepare and review financial statements through month-end close and reporting coordination
• Gather and analyze complex financial information and formulate recommendations for senior management
• Provide technical guidance on accounting and fiscal procedures
• Evaluate accounting and reporting controls and implement corrective action plans
• Support projects that improve or facilitate accounting and reporting functions
• Review journal entries and account reconciliations and assist with monthly close activities
• Manage or perform GAAP/SAP accounting and reporting functions
• Participate in financial accounting issue resolution and procedural changes
• Set up and maintain accounting systems, charts of accounts, and reporting subsystems
• Provide leadership, coaching, support, problem-solving assistance, and knowledge transfer
• Research technical accounting pronouncements, regulatory bulletins, and industry information; prepare analyses and recommendations
• Perform due diligence reviews, review deal structures, and evaluate accounting implications
• Initiate process and control improvement projects and participate in cross-functional finance projects
• Review GAAP/SAP monthly, quarterly, and annual financial reports
• Collaborate with other BCBS plans and the BCBSA to resolve accounting and reporting issues
• Assist auditors by providing requested information, resolving issues, and drafting resolutions
• Maintain and enhance internal controls and perform self-testing

Senior Accountant

Actuary

• Perform actuarial research, experience studies, and statistical analyses and calculations
• Calculate premiums and reserves for new and existing insurance plans
• Support senior analysts or actuaries
• Retrieve and validate data for rate filings and actuarial models
• Build model enhancements and determine reasons for changes to calculated factors
• Analyze impacts of changes to product lines and segments
• Communicate filing status to internal stakeholders and transmit rate filings to regulatory agencies, including NCDOI and CMS
• Retrieve and validate data for monthly reports and UCL and ALR calculations
• Support valuation by executing the ALR model and verifying results
• Research to support ALR assumption studies and UCL estimates
• Distribute established reports and respond to inquiries
• Investigate trends and anomalies
• Execute control activities supporting Enterprise Risk Management
• Provide analytic support for corporate and departmental projects
• Participate in good standing in the Actuarial Development Program
• Provide actuarial expertise and consultative support to Finance, Underwriting, Sales & Marketing, Network Management, Healthcare, and other business areas

Actuarial Analyst

Team Leader

• Manage day-to-day workload to achieve business objectives and execute team goals
• Provide leadership, direction, work-process assistance, and operational support to the team
• Foster a positive, accountable, and collaborative team culture
• Serve as primary contact for operational updates and escalations, including customer-facing engagement
• Ensure employees are trained in processes and procedures and respond accurately to inquiries
• Provide coaching, development feedback, and formal performance evaluations
• Establish performance goals and monitor progress with departmental and cross-functional teams
• Identify and address system or process gaps
• Identify trends, determine root causes, and initiate corrective action
• Document and report system and process problems and implement solutions
• Conduct random audits and create performance improvement plans as needed
• Develop and implement approved short- and long-term service objectives and methods
• Respond to escalated client and customer issues
• Represent the department on corporate projects

Team Leader, Coordination of Benefits

Claims Specialist

• Review and timely adjudicate claims in accordance with contractual benefits and health care policies
• Administer claims and manage daily work queues
• Process, adjust, or update moderate to complex claims payments and payment errors
• Respond to inquiries regarding claims payments from customer service professionals, subscribers, providers, physicians, and other insurance carriers
• Meet or exceed established quality and performance standards
• Determine suspended claim resolution methods by reviewing benefit eligibility, claims history, and other information
• Escalate claims requiring specialized resolution to subject matter experts
• Understand business requirements for customer and provider segments and provide tailored solutions
• Identify system issues, document them, recommend potential solutions, and refer them to technical staff
• Work with Provider Services specialists to deliver tailored services
• Review claims for possible fraud and abuse and refer them to the Special Investigations Unit
• Drive efficiency and production gains through continuous improvement and share best practices
• Coordinate with other insurance carriers and Medicare to determine BCBSNC payment liability
• Represent Claims interests on divisional or enterprise project teams
• Monitor claim turnaround times to ensure compliance guidelines and performance guarantees are met

• Coordinate care, resources, and services for selected member populations
• Provide guidance and promote effective utilization and monitoring of health care resources
• Collaborate with healthcare team members to achieve optimal clinical and resource outcomes
• Perform comprehensive assessments and coordinate treatment, interventions, and discharge planning
• Develop member-centric plans based on needs, health status, education, and support requirements
• Identify barriers to goals and plans of care
• Utilize community resources and funding sources
• Monitor and manage members through follow-up, education, referrals, documentation, and plan modifications
• Evaluate and facilitate care across the continuum, including physician offices, hospitals, rehabilitation units, skilled nursing facilities, and home care
• Educate members and encourage proactive intervention
• Document assessments, plans, implementation, monitoring, and outcomes
• Outreach to high-risk, high-cost, or high-utilization members when needed
• Review alternative treatment plans and assess benefits, exceptions, or flex benefit options
• Evaluate medical necessity and appropriateness of services
• Develop policies, procedures, education, or training as needed

• Coordinate care, resources, and/or services for selected member populations
• Provide guidance and promote effective utilization and monitoring of health care resources
• Collaborate with healthcare team members to achieve optimal clinical and resource outcomes
• Perform comprehensive assessments and coordinate treatment, interventions, and discharge planning
• Develop member-centric plans of care and identify barriers to goals
• Utilize community resources and funding sources
• Monitor and manage members through follow-up, education, referrals, documentation, and plan modifications
• Evaluate and facilitate care across the continuum, including physician offices, hospitals, rehabilitation units, skilled nursing facilities, and home care
• Educate members and encourage proactive intervention
• Document assessments, plans, implementation, monitoring, and outcomes
• Potentially outreach to high-risk, high-cost, or high-utilization members
• Potentially review alternative treatment plans, benefits exceptions, and flex benefit options
• Potentially evaluate medical necessity and service appropriateness
• Develop policies, procedures, education, or training as needed

Solutions Engineer

• Lead enterprise architecture efforts by defining solution strategies, architecture roadmaps, standards, and reference models
• Serve as lead architect for complex initiatives across business stakeholders, technology teams, vendors, and delivery organizations
• Design and govern scalable enterprise data architectures aligned with data quality, governance, metadata management, analytics, compliance, and business requirements
• Drive architecture decisions across cloud platforms, data and analytics solutions, system integrations, APIs, event-driven architectures, databases, and application development
• Establish and enforce architectural standards, patterns, governance processes, and security requirements
• Evaluate emerging technologies, conduct proofs of concept, and recommend innovative solutions
• Identify and mitigate technical risks, architecture gaps, and solution dependencies
• Guide architecture activities throughout the SDLC with Agile delivery teams
• Provide technical leadership, mentoring, and coaching to architects, engineers, and technology teams
• Influence strategic technology decisions and communicate architectural vision, recommendations, and trade-offs to executive and technical audiences

Principal Solution Architect – Data Focus

Strategy

• Identify, evaluate, and implement healthcare redesign, provider reimbursement, and partnership strategies
• Support development of current products and market offer components
• Execute strategic planning, complex financial and qualitative analysis, and thought leadership
• Present strategic concepts, planning data, medical expense/reimbursement rates, provider performance metrics, and impact assessments to internal and external audiences, including senior leadership
• Organize, optimize, and communicate progress toward completion of the overall work portfolio
• Collaborate with departments across the enterprise on common initiatives and unique ventures
• Serve as a subject matter expert for healthcare delivery transformation and/or healthcare reimbursement and strategy
• Identify, analyze, and monitor industry, regulatory, technology, and market trends
• Identify operational improvements using analysis/reporting capabilities, project management techniques, and consulting/engagement approaches

Senior Strategic Advisor

Operations

• Lead, manage, and set goals for teams responsible for initiatives and activities that create efficiencies, optimize systems and processes, and promote quality
• Provide leadership, vision, and direction for assigned teams and make group-level decisions
• Determine team priorities aligned with organizational values and deliverables
• Develop, coach, and motivate staff
• Develop and manage departmental budgets, including forecasting and variance analyses
• Lead process improvement, root cause analysis, system enhancement, re-engineering, and continuous improvement initiatives
• Direct subject matter experts and analysts supporting business initiatives, production problem resolution, system enhancements, and configurations
• Lead enterprise and departmental project delivery, including business case development, ROI analysis, planning, business analysis, and project management
• Oversee optimization of systems, processes, workflows, and call-center workforce planning
• Direct the integrity and functionality of departmental business applications and processes
• Oversee system administration, configuration coding, and application configuration
• Support product implementation and enhancements
• Research and assess technology and systems to ensure adequate application support
• Lead quality programs, training, and policy and procedure development and documentation, including external audit programs
• Serve as business owner for the Clinical Cod Reporting Team (CCR) and related corporate, divisional, and departmental initiatives

Case Manager

Senior Developer

Client Financial Associate

Senior Financial Advisor

Client Financial Analyst

Senior Insights Analyst

Senior Accountant

Actuarial Analyst

Team Leader, Coordination of Benefits

Claims Specialist

Case Manager

Case Manager

Principal Solution Architect – Data Focus

Senior Strategic Advisor

Director, Operations Support