Blue Cross NC

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

Director, Operations Support

Analyst

• Analyze, manage, and provide tactical and strategic expertise to portfolios of strategic and complex initiatives and projects
• Ensure data integrity and deliver accurate reporting, portfolio health monitoring, and decision-ready insights across intake, pipeline, and project delivery
• Strengthen delivery readiness and identify emerging risks and trends
• Synthesize capacity, demand, readiness, financial, dependency, and performance data to support prioritization, governance, and investment decisions
• Develop and continuously improve processes, standards, policies, and templates
• Monitor portfolio performance metrics and key indicators, identifying trends, risks, and opportunities
• Translate portfolio data into clear observations and implications for stakeholders and leadership
• Analyze project financials and identify emerging budget, funding, and delivery risks
• Monitor projects to ensure realized business value and manage portfolio-level risks, issues, and dependencies
• Support portfolio reviews, governance forums, and leadership updates
• Prepare executive-level status reports and presentations regarding portfolio health and status
• Provide backup support for Portfolio Leaders during absences, transitions, or peak demand
• Assess customer/client satisfaction through direct feedback and evaluation
• Lead continuous improvement initiatives focused on enterprise efficiencies
• Serve as a subject matter expert for project and portfolio tools and methodologies
• Maximize use of the portfolio planning tool for planning processes
• Train and coach others

Senior Portfolio Analyst

• Lead a team of departmental staff and oversee workload and execution of operational goals
• Manage day-to-day workload, provide leadership and direction, and execute team goals and expectations
• Assist the team with work processes and procedures
• Foster a positive, accountable, and collaborative team culture
• Serve as the primary point of contact for operational updates and escalations, including customer-facing engagement as needed
• Ensure employees are trained in processes and procedures and respond professionally, courteously, quickly, and accurately to inquiries
• Provide ongoing coaching and development feedback and conduct performance evaluations
• Collaborate with departmental and cross-functional teams to establish performance goals and monitor progress
• Identify and address system or process gaps
• Identify trends, determine root causes, document and report problems, and implement solutions
• Conduct random audits, review results, and create performance improvement plans as necessary
• Develop and implement short- and long-term service objectives and methods when approved
• Respond to escalated issues from clients and customers
• Represent the department on corporate projects as needed
• Maintain member and customer satisfaction and compliance with applicable requirements

Team Leader, Operations – Member Outreach

Vice President

• Provide strategic direction and centralized leadership for provider payment integrity and reimbursement policy functions
• Lead prepayment clinical and coding requirements and post-payment recoupment efforts
• Promote accuracy in claims payment and correct coding to drive savings
• Lead strategies for reimbursement policy development, claims editing, post-payment analytics and recoupment, provider education, coordination of benefits, and innovative payment integrity programs
• Oversee enterprise payment integrity initiatives that advance affordability, payment accuracy, and operational excellence
• Assess the Payment Integrity ecosystem, prioritize high-value opportunities, and establish KPIs
• Develop and execute an enterprise-wide Payment Integrity strategy
• Lead programs focused on payment accuracy, claims integrity, coding validation, recovery operations, and coordination of benefits
• Leverage advanced analytics, automation, and emerging technologies to identify opportunities, reduce waste, and improve outcomes
• Establish performance metrics, governance frameworks, and reporting to measure business impact and value realization
• Partner with provider-facing teams to balance payment accuracy with a positive provider experience
• Manage a high-performing multi-vendor portfolio by enforcing SLAs, optimizing fee structures, and minimizing provider abrasion
• Advise executive leadership on payment integrity trends, risks, opportunities, and industry best practices
• Build and develop a high-performing team while fostering innovation, accountability, and continuous improvement
• Partner across Finance, Medical Economics, Provider Network Management, Clinical Operations, Technology, Compliance, and Legal

VP, Payment Integrity

General Counsel

• Provide legal support for Blue Cross NC’s Pharmacy Benefit Manager services, including services provided to the North Carolina State Health Plan
• Develop and maintain working knowledge of PBM contracts and related legal requirements
• Review PBM materials, communications, program documents, policy updates, vendor submissions, and other work product
• Advise business partners on PBM contractual requirements related to pharmacy administration, claims processing, formulary support, rebates, pricing, reporting, member communications, audits, and vendor performance
• Serve as legal counsel supporting the PBM business and administration of the State Health Plan PBM contract
• Advise on federal and state legal and regulatory requirements affecting pharmacy benefits and health plan administration
• Support pharmacy benefit initiatives, benefit changes, vendor integrations, member communications, reporting processes, and operational workflows
• Advise on privacy, security, data governance, confidentiality, and information-sharing requirements
• Support responses to audits, investigations, administrative inquiries, regulatory requests, compliance reviews, and information requests
• Assist with public records requests and confidentiality analyses
• Monitor legal, regulatory, legislative, and market developments and communicate implications to stakeholders
• Provide legal support for member complaints, appeals, grievances, claims administration issues, pharmacy network issues, benefit interpretation, and vendor disputes
• Develop and deliver training on legal, regulatory, contractual, and compliance topics
• Provide support on developing legal issues and perform other duties as assigned

Associate Counsel – Pharmacy Benefit Management

• Serve as dedicated legal counsel supporting Blue Cross NC's administration of the State Health Plan TPA contract
• Provide day-to-day legal guidance on operational, contractual, regulatory, and implementation matters
• Develop and maintain subject matter knowledge of the State Health Plan contract, including performance guarantees, service levels, reporting obligations, implementation requirements, financial provisions, audit rights, and operational commitments
• Research and analyze federal and state laws, regulations, administrative guidance, and case law applicable to health plans, government programs, and third-party administration services
• Draft, review, and negotiate provider agreements, data sharing agreements, vendor agreements, business associate agreements, amendments, and operational documentation
• Support implementation and ongoing administration of State Health Plan initiatives, benefit changes, network arrangements, and vendor integrations
• Advise on HIPAA, HITECH, privacy, security, data governance, and information-sharing requirements
• Support responses to audits, investigations, administrative inquiries, regulatory requests, and contractual compliance reviews
• Assist with public records requests, confidentiality analyses, and protection of trade secret and proprietary information
• Monitor legal, regulatory, and legislative developments and communicate practical implications to business stakeholders
• Provide legal support related to appeals, grievances, provider disputes, claims administration issues, and member complaints
• Develop and deliver training on legal and compliance topics
• Support strategic initiatives involving value-based care, alternative payment models, provider contracting, and network innovation
• Draft and review executive communications, board materials, regulatory responses, and other business-facing legal guidance
• Provide support on developing legal issues and perform other duties as assigned

Associate Counsel – State Health Plan Administration

Product Manager

• Manage the team and sprint backlog
• Prioritize work aligned to the customer roadmap
• Deliver value across complex, high-impact, and/or multiple products with minimal oversight
• Ensure customer desires and business priorities are communicated and reflected in the product backlog
• Collaborate with stakeholders and team members to define user stories
• Own the team/sprint backlog in collaboration with delivery teams
• Decompose features into stories or smaller work items
• Map product vision to user stories using Product Manager and stakeholder input
• Act as liaison between the business/customer and delivery team
• Represent the expectations of interested stakeholder segments
• Develop and maintain business knowledge for the assigned Spoke or business area
• Define user stories and support team members as they write user stories
• Mentor and coach other staff

Senior Product Owner

Strategy

• Identify, evaluate and lead implementation of healthcare redesign, provider reimbursement and partnership strategies
• Support and manage development efforts for current products and market offer components
• Lead strategic planning, complex quantitative and qualitative analysis, and thought leadership at departmental and enterprise levels
• 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 enterprise departments 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
• Drive operational improvements through new analysis/reporting capabilities, project management techniques and consulting/engagement approaches
• Mentor and coach junior team members and may oversee other staff

Principal Strategic Advisor, Healthcare

• Identify simple to moderate business requirements and solutions for packaged system software implementation
• Configure and administer packaged software
• Participate in process design and system testing
• Serve as subject matter expert for an existing application area
• Assist with packaged software modification requirements and interface design specifications
• Establish and maintain packaged software file configurations
• Perform discovery and fact-finding for assignments
• Liaise with business areas during development and implementation
• Identify, communicate, and implement departmental best practices
• Analyze application and system problems and incidents with support
• Develop, implement, and communicate recommendations and solutions
• Complete project tasks within allocated time and budget
• Provide direction to junior staff and support senior team members
• Provide configuration expertise and consultative support to customers and business partners
• Perform SDLC activities, including solution design, code development and maintenance, unit testing, and technical documentation

Business Applications Analyst

Systems Engineer

• Manage the maintenance and optimization of Actuarial Systems Data Marts
• Perform monthly data refreshes, financial validations, and quality assurance checks for actuarial reporting and analytics
• Analyze business problems and opportunities; develop, recommend, and implement solutions
• Develop decision-support solutions, including medical and pharmacy claim financial data builds, data extracts, reports, data mart tables, views, and analysis
• Ensure financial granular-detail data is auditable, snapshotted, and stored for quarterly and year-end audits
• Establish vendor and inter-departmental relationships to ensure financial data accuracy and completeness
• Monitor company and external-vendor changes affecting departmental processes and systems; recommend and implement updates
• Lead multiple application areas, including data definitions, usage and file structure, code technical structure, business rules, and requirements
• Provide technical leadership and application expertise to business project teams
• Liaise with business areas during development and implementation
• Provide configuration expertise and communicate with customers and business partners through verbal, written, electronic communication, and presentations
• Provide analytical support for departmental, divisional, and corporate projects

Senior Actuarial Data Systems Analyst

• Assist in developing, designing, and testing data sets delivered through Actuarial data marts
• Assist with monthly data refreshes, validations, and quality assurance checks for financial reporting
• Develop decision support solutions, including medical and pharmacy claim financial data builds, data extracts, reports, data mart tables, views, and analysis
• Support data application areas, including data definitions, usage and file structure, SQL code technical structure, business rules, and system requirements
• Identify, communicate, and implement departmental best practices
• Analyze data, system problems, and incidents; develop and implement recommendations and solutions
• Communicate associated actions, business impacts, and results
• Provide data support to senior team members on business project teams and non-project activities
• Perform unit testing and create sample data sets to validate SQL code and logic
• Provide analytical and ad hoc support for departmental, divisional, and corporate projects
• Write system and technical specifications

Actuarial Data Systems Analyst

• Identify and lead innovative pharmacy strategies that reduce cost of care, improve member outcomes, and support enterprise growth
• Develop and optimize pharmacy products, programs, and partnerships to create new revenue streams and enhance market competitiveness
• Evaluate emerging industry, regulatory, and technology trends to identify strategic opportunities and risks
• Conduct complex financial, operational, and market analyses to support strategic decision-making and investment priorities
• Present strategic recommendations and business insights to senior leadership and key stakeholders
• Build and manage relationships with PBMs, vendors, and partners to accelerate innovation and value creation
• Serve as a pharmacy strategy expert and collaborate across the enterprise to advance business objectives
• Lead the execution, measurement, and continuous improvement of strategic initiatives that deliver sustainable enterprise value

Senior Strategic Advisor, Healthcare

Business Operations

• Facilitate strategic-goal planning and develop departmental/divisional operational plans
• Produce segment business plans and analysis under guidance from the Segment Lead
• Coordinate departmental/divisional events, meetings, and leadership planning sessions
• Support workforce planning, staffing models, and tracking of employee hires against budgets and competencies
• Aid adoption and communication of standard operating procedures and processes
• Lead change-management work supporting business and process improvements
• Handle special projects, including cost-reduction and efficiency evaluations
• Review best or next practices and industry literature; brief leadership on relevant issues
• Lead engagements with external entities and coordinate data-gathering and research efforts
• Track initiatives and projects and prepare progress presentations for varied audiences, including senior leadership
• Consolidate and standardize business-operations data analysis and reporting
• Perform departmental budget analysis and monitor forecasts and cost-reduction goals
• Track goals through collection and analysis of key performance indicators
• Support internal and external partnership meetings and capture follow-up actions
• Prepare input for annual, CEO, Board, marketing, and communications reports
• Support leadership public-speaking engagements and industry Board and Committee meetings
• Manage vendor relationships as required by business operations

Business Operations Advisor

Manager

• Manage day-to-day relationships between business stakeholders and vendors
• Serve as the primary communicator and liaison between vendors and business stakeholders
• Provide performance metric updates, manage capacity and demand, and remediate escalations
• Facilitate vendor onboarding through communications, site visits, and training
• Educate vendors on program, product, and operational details
• Transition business processes and/or operations successfully
• Partner with business leads to define evolving service needs, expectations, and requirements
• Analyze performance gaps and address them through process improvements, training, or other interventions
• Review vendor work for quality issues and manage service improvement plans
• Provide input to vendor contract negotiations
• Collaborate with internal business partners on vendor strategy discussions
• Provide data, knowledge, and feedback on vendor operations

Vendor Manager

Claims Specialist

• Review and timely adjudicate claims
• Administer claims in accordance with contractual benefits and health care policies
• Manage daily work queues and claims processing quality
• Monitor claim turnaround times for compliance guidelines and performance guarantees
• Process, adjust, or update routine claims payments and payment errors
• Respond to inquiries from service teams, subscribers, providers, physicians, and other insurance carriers
• Determine suspended claim resolution methods by reviewing benefit eligibility, claims history, and other information
• Identify system problems, document issues, recommend solutions, refer issues to technical staff, and follow up on resolution
• Assist management by identifying and analyzing process, policy, and service improvement opportunities
• Coordinate with other insurance carriers and Medicare to determine payment liability
• Review claims for possible fraud and abuse and refer them to the Special Investigations Unit