Blue Cross NC

General

• Conduct nonclinical reviews based on applicable criteria and guidelines for requested services
• Communicate review decisions to providers and/or members according to department protocols
• Document review outcomes and interpret and analyze non-clinical information
• Conduct outreach to providers or members to obtain medical information
• Identify and refer determinations requiring clinical review to a nurse or Medical Director
• Review authorizations for accuracy to avoid impacts on claims payment
• Support care management through member and provider outreach to meet CMS information solicitation and notification standards
• Retrieve and attach facsimiles to forward customer requests for processing
• Serve as a subject matter expert on the non-clinical review process for CM&O

Utilization Management Specialist

• Conduct nonclinical reviews of requested services based on applicable criteria and guidelines
• Communicate review decisions to providers and/or members according to department protocols
• Document review outcomes and interpret and analyze non-clinical information
• Contact providers or members to obtain medical information for reviews
• Identify and refer organization determinations requiring clinical review to a nurse or Medical Director
• Review authorizations for accuracy to help avoid claims payment impacts
• Complete outreach to members or providers to support CMS information solicitation and notification standards
• Retrieve and attach facsimiles and forward customer requests to the appropriate processing area
• Serve as a subject matter expert for CM&O on the non-clinical review process
• Provide administrative support to help meet departmental turnaround times

Solutions Engineer

• Improve organizational performance through strategic consulting, performance analysis, learning design, and business partnership
• Serve as a trusted advisor to senior leaders, directors, and vice presidents
• Build understanding of business objectives, operational challenges, performance metrics, and workforce strategies
• Participate in strategic planning to identify workforce capability implications
• Influence leaders toward root-cause solutions
• Conduct performance consulting engagements and diagnose workforce challenges and performance opportunities
• Assess business, operational, behavioral, process, technology, knowledge, organizational, leadership, communication, incentive, and accountability factors
• Design comprehensive learning and learning-adjacent solutions, including formal learning programs, digital learning experiences, performance support tools, in-the-flow-of-work learning, knowledge management strategies, AI-enabled learning and support, coaching frameworks, leader enablement, change and adoption strategies, and communications campaigns
• Lead conversations with senior leaders and executive stakeholders
• Translate complex problems into concise, actionable business insights
• Use storytelling to make data meaningful and drive decisions
• Create executive-ready presentations and consultation materials
• Analyze business performance metrics, learner data, operational KPIs, workforce trends, and stakeholder feedback
• Identify patterns, opportunities, risks, and emerging capability needs
• Synthesize data sources into narratives and recommendations
• Use qualitative and quantitative insights to guide solution design and prioritization
• Serve as a subject matter expert within Learning & Development
• Introduce innovative practices, technologies, and methodologies
• Maintain expertise in learning strategy, performance consulting, organizational effectiveness, workforce transformation, and AI-enabled learning
• Influence enterprise learning strategy and operating models
• Manage multiple projects and programs with focus on customer service and timely execution

Principal Learning Solutions Architect

Manager

• 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 tailored to needs, health status, education, and support requirements
• Identify barriers to goals or plans of care and utilize community resources and funding sources
• Monitor and manage members through follow-up, education, referrals, documentation, and plan modification
• Evaluate and facilitate care across physician offices, hospitals, rehabilitation units, skilled nursing facilities, and home care
• Educate members and encourage proactive intervention to limit expense and improve outcomes
• Document assessment, planning, implementation, monitoring, and outcomes
• Outreach to high-risk, high-cost, or high-utilization members as needed
• Review alternative treatment plans, benefits, exceptions, and flex benefit options
• Evaluate medical necessity and appropriateness of services
• Develop policies, procedures, education, or training as needed

Case Manager

Crypto

• Intake granular application-specific knowledge as the customer experience subject matter expert
• Provide customer experience insights to shape business needs and requirements
• Advocate for digital customer experience best practices and customer needs
• Collaborate with internal user experience and design experience stakeholders on customer experience research
• Coordinate development of team experience projects
• Generate practical, sustainable, and creative recommendations to solve online customer experience delivery issues
• Combine application analysis and strategy to provide data-driven enhancement recommendations
• Create charts, slide presentations, reports, and dashboards tied to application KPIs, feature KPIs, and VOC research
• Present analysis and recommendations to the product solutions team
• Provide ad hoc reporting, answers to questions, queries, and problem support
• Present applications and explain how customer experience affects business outcomes
• Validate data and metrics sources and refine back-end data modeling using front-end data
• Identify complex trends across applications and recommend actions to product solutions teams
• Perform application-specific comparative testing to optimize customer experience
• Maintain detailed application-specific customer experience analysis documentation
• May serve as point of contact for enterprise audit processes and procedures

Digital Asset Management Librarian

Team Leader

• Supervise staff processing appeals, coding disputes, grievances, and coverage/organization determinations
• Oversee daily operations, case-load assignments, and team priorities
• Ensure resolutions comply with organizational policies, state and federal guidelines, and regulatory/accreditation requirements
• Prepare for Appeals Committee and panel meetings
• Handle or direct difficult customer calls regarding appeals, coding disputes, grievances, or quality issues
• Develop efficient and effective workflows and processes with staff
• Advise and instruct staff on operational goals, policies, and communications to providers and members
• Evaluate data requests and ensure data requirements are met
• Assist staff and management with information needs
• Complete ad hoc reporting and assigned projects/interventions
• Improve operations, resolve cross-team issues, and allocate resources across departments and divisions

Utilization Management Specialist

Utilization Management Specialist

Principal Learning Solutions Architect

Case Manager

Digital Asset Management Librarian

Team Leader – Appeals