Cambia Health Solutions

Project Manager

• Support marketing, sales support, and communications projects through completion
• Maintain accountability for budget, planning, production, and deadlines
• Participate in meetings with marketing and sales staff to develop strategies
• Coordinate timely production of sales and marketing materials, including AEP document production
• Coordinate dissemination of collateral and marketing materials to designated sources
• Provide summary reviews of marketing and sales projects to key stakeholders
• Monitor creative services, web services, and vendor production and delivery
• Provide updates and ensure adherence to schedules
• Prepare reporting and analysis documents for marketing and sales communications activities
• Coordinate timely production of sales materials and manage related production processes

Marketing Project Manager II – Employer and Producer Marketing

Analyst

• Retrieve, abstract, and/or over-read medical records to capture required HEDIS reporting data elements
• Collect member medical records from EMR/EHR systems
• Review electronic medical records for required documentation
• Download medical record images to corporate drives
• Log receipt and retrieval progress in appropriate software
• Pursue records by phone, fax, mail, or direct onsite pickup when needed
• Abstract and/or over-read pertinent medical record data and enter it into the specified HEDIS database
• Prepare assigned records for medical record abstraction
• Communicate effectively and professionally with provider offices
• Document abstraction findings using designated paper and electronic tools
• Communicate additional pursuit strategies to HEDIS team members
• Support HEDIS reporting and Quality Improvement

HEDIS Medical Record Analyst – Temporary

Clinician

• Perform comprehensive prospective, concurrent, and retrospective utilization management reviews
• Ensure adherence to medical necessity and policy standards
• Apply clinical expertise and evidence-based criteria to make determinations
• Consult physician advisors as necessary
• Collaborate with interdisciplinary teams, case management, and other departments to facilitate transitions of care and resolve issues
• Respond promptly and accurately to internal and external inquiries
• Provide exceptional customer service
• Identify improvement opportunities and participate in quality improvement initiatives
• Maintain accurate and consistent documentation
• Prioritize assignments to meet performance standards and corporate objectives
• Protect confidential information
• Communicate professionally with members, providers, and regulatory organizations

Behavioral Health Utilization Management Clinician

Network Engineer

• Review cases concerning medication effectiveness, safety, cost, and treatment options
• Review scientific research and assign letter grades for medication effectiveness
• Supplement effectiveness reviews with cost information
• Provide evidence-based medication guidance to help people choose treatment options
• Review available cases on a flexible, self-directed schedule
• Return an Ask a Pharmacist response within 24 hours
• Complete cases for a flat rate per case
• Speak with a doctor or patient by phone when requested
• Receive alerts when cases are available for review

Contract Digital Medication Support Network Pharmacist

• Review cases concerning medication effectiveness, safety, cost, and treatment options
• Review scientific research and assign letter grades for medication effectiveness
• Supplement medication guidance with cost information
• Help people find the best treatment option for their lifestyle
• Review available cases on a flexible, self-directed schedule
• Return an Ask a Pharmacist response within 24 hours
• Communicate by phone with a doctor or patient when requested
• Complete cases as an independent contractor

Clinical Specialist

• Receive, research, and take action on documentation and requests related to Inpatient Utilization Management cases
• Partner with licensed health professionals on appropriate actions and responses; role does not make clinical decisions
• Research and review inpatient Utilization Management requests for completeness
• Obtain necessary details and complete non-clinical tasks to close cases accurately and efficiently
• Communicate with internal and external stakeholders, including providers and team members
• Facilitate written notifications in compliance with regulatory and quality requirements
• Manage UM activities to meet timeliness, production, quality, corporate, federal, state, BCBSA, and accreditation standards
• Organize and maintain reference documents, policies, and procedures
• Perform detailed research and problem-solving to ensure case accuracy and completeness
• Identify opportunities to improve systems and workflows
• Initiate referrals to adjacent teams as needed
• Discuss discharge planning with providers as needed
• Assist with systems testing when needed

Utilization Management – Inpatient Clinical Specialist

Customer Support

• Serve as the Partners in Care department's subject matter expert
• Support and coach Customer Service staff
• Handle and resolve escalated and complex calls, claims, and inquiries from members, providers, employer groups, and healthcare professionals
• Research and resolve claims, benefit administration errors, appeals, and correspondence issues according to company policy and regulations
• Explain benefits, eligibility, claims procedures, pre-authorizations, and grievance/appeal processes
• Coach, mentor, and support Customer Service staff through one-on-one guidance, help line support, training, and onboarding
• Collaborate with Medical, Legal, Provider Relations, Claims, and Pharmacy Services
• Analyze data and trends to identify recurring issues
• Provide ongoing education and recommendations to Customer Service leadership
• Ensure issue resolution aligns with corporate policy and regulatory requirements
• Serve as subject matter expert on company policies, products, processes, and Coordination of Benefits

Customer Service Ambassador

• Complete the clinical component of all appeal types to resolve member and/or provider appeals
• Apply nursing expertise and clinical judgment to ensure written appeal decisions comply with medical policy, medical necessity guidelines, reimbursement policies, federal regulations, company policy, industry standards and accepted standards of care
• Conduct clinical appeal reviews adhering to member benefits and provider and hospital contracts
• Consult with physician advisers to ensure clinically appropriate determinations when required
• Advise and educate non-clinical appeals staff on clinical cases

Appeals Clinician I

Insurance

• Lead the Risk Management Business Team responsible for CMS-mandated Enrollment, Medical Claim and Pharmacy Claim data submissions for Reinsurance and Risk Adjustment programs
• Lead extraction of required information from source systems into a staging area
• Oversee validation checks based on CMS Edge Server Business Rules
• Submit correct data to the Edge Server through a translation process
• Collaborate with IT, compliance, legal, revenue management, claims, enrollment, product and other departments
• Oversee RADV audits, submit data timely and prepare executive reports
• Develop medical underwriting rules for the Risk Management business system
• Direct business projects and deliver project performance criteria and objectives
• Support day-to-day operations, identify issues and recommend solutions
• Develop and review business policies, processes and practices
• Develop, implement and monitor audit processes for Edge Server utilization
• Create and deliver training materials
• Partner with IT to resolve data submission system issues
• Manage staff development, performance conversations, coaching and retention activities
• Communicate departmental and organizational goals to staff
• Maintain departmental policies and procedures and ensure adherence to standards
• Oversee the data submission system
• Travel rarely, locally or out of state

Manager, Risk Management – Business Team

• Triage selected claims against clinical review and audit criteria
• Request and obtain provider medical records via letters or EMR
• Receive, research, and process incoming records via fax, mail, email, and secure upload
• Input claim processing instructions into Facets
• Update required fields and notes in the department database
• Interpret claim history and pre-authorization determinations as needed
• Communicate with claims staff and Network Management regarding claim status and needed or missing records
• Send detailed notification letters to providers
• Meet production requirements and quality standards while following federal, state, BCBSA, and accreditation regulations
• Remain flexible and cross-trained on other functions to support department efficiency

Medical Records Analyst I

General

• Analyze, develop, and monitor health benefit offerings
• Lead ongoing benefit development activities, including auditing complex benefit contracts
• Oversee benefit change proposals to ensure compliance with state and federal laws
• Track, analyze, and present regulatory updates to the Product Platform Team
• Respond to regulator inquiries regarding benefit design and compliance
• Partner with Product Development, Sales, Actuarial, and Marketing Communications teams
• Implement, communicate, and monitor benefit-related activities
• Lead Medicare PPO benefit design bid submissions to CMS
• Conduct competitive research and benefit analysis
• Analyze competitive benefit trends and communicate strategic implications to management
• Prepare and deliver benefit presentations and training to internal and external audiences
• Respond to RFP/RFI proposals regarding benefit information and design
• Provide direction to the team, engage team members toward common goals, and foster a positive team experience

Benefit Development Specialist II/III

Director

• Lead the Affordability Program Office and/or one or more Affordability Levers
• Lead the end-to-end affordability portfolio from opportunity identification and solution design through business case development, contracting, implementation, performance management, and value realization
• Partner with Affordability Owners and cross-functional leaders to establish priorities, align resources, remove barriers, and drive accountability
• Advance standardized governance, portfolio management, and operating practices
• Define and execute the Cost Stewardship strategic roadmap with VP and senior leadership
• Lead annual planning, initiative prioritization, and portfolio management across Clinical/Medical Management, Payment Integrity, Network Management, and Pharmacy levers
• Manage the initiative lifecycle with clear milestones, ownership, business rationale, and value accountability
• Monitor portfolio execution, identify dependencies and barriers, escalate blockers, and ensure timely delivery of savings targets
• Develop solutions and business cases with Health Informatics, Finance, Actuarial, and subject-matter experts
• Establish governance, reporting, decision frameworks, execution meetings, dashboards, and executive communications
• Develop standardized portfolio, project execution, business case, milestone tracking, governance, accountability, and change management tools
• Evaluate build-versus-buy opportunities and oversee strategic vendor relationships
• Coach and develop a high-performing team
• Supervise 3–8 direct FTEs

Assistant Director – Affordability

Nurse

• Conduct prospective, concurrent, and retrospective utilization management reviews
• Ensure medical necessity and compliance with policy and standards of care
• Apply clinical expertise and evidence-based criteria to make determinations
• Consult with physician advisors as needed
• Collaborate with interdisciplinary teams, case management, and other departments
• Facilitate transitions of care and resolve issues
• Serve as a resource to internal and external customers
• Provide accurate and timely responses to inquiries
• Identify improvement opportunities and participate in quality improvement efforts
• Maintain accurate and consistent documentation
• Prioritize assignments to meet performance standards and corporate goals
• Protect confidentiality of sensitive documents and issues
• Communicate professionally with members, providers, and regulatory organizations

Utilization Management Nurse

• Develop strategy and oversee reimbursement and coding policy activities
• Drive operationalization of internal and vendor Payment Integrity opportunities
• Lead correct coding and reimbursement reviews and methodologies
• Assess and develop policies
• Lead the Reimbursement Policy Committee
• Consult on system-wide implementation of payment policies
• Establish an ongoing ideation and Payment Integrity initiative development team
• Act as a key stakeholder in trend management
• Direct the coding disputes team
• Optimize payment edits and rules across internal and vendor-supported applications
• Lead strategic planning and execution of reimbursement policy, coding disputes, and Payment Integrity ideation initiatives
• Track programs, develop financial justifications, and prioritize initiatives with Healthcare and Clinical Services leadership, legal, and healthcare informatics
• Develop budgets, policies, workflows, and change management plans
• Monitor results and metrics to ensure strategic goals, deliverables, and regulatory compliance
• Oversee enterprise stakeholder vetting of proposed reimbursement policies
• Direct innovation teams and coding dispute resolution
• Develop and execute affordability initiatives across tools and levers
• Provide strategic viewpoints and long-term roadmaps for reimbursement policy and Payment Integrity strategies
• Consult on legislative and regulatory issues
• Maintain program governance, accountability, deliverables, risks, dependencies, and escalations
• Direct data infrastructure systems, enhancements, and upgrades
• Evaluate IT infrastructure business needs
• Develop team KPIs and metrics
• Collaborate in the RFP process
• Provide direction to teams and foster a positive team experience
• Supervise 3–6 direct FTEs and 40–60 total FTEs

Assistant Director – Payment Integrity Policy, Implementation

Product Manager

• Own MedInsight product strategy and roadmap for inbound Milliman-enriched data, outbound MedInsight extracts, Healthcare Intelligence views, and related enriched data products
• Manage MedInsight operational readiness and product support, including enhancements, defects, releases, vendor delivery questions, validation findings, escalations, and change communications
• Translate business objectives, actuarial methodology, data lineage, data quality needs, and analytic consumption patterns into product requirements, acceptance criteria, and delivery priorities
• Advance governed semantic layers, AI-powered insight discovery, automated data discovery, agentic self-service, analytic service management, and responsible AI practices
• Partner with Actuarial, Healthcare Informatics, Finance, Clinical, Care Management, Provider Analytics, Engineering, Data Governance, Architecture, Operations, and Milliman teams
• Lead cross-functional delivery and tradeoff decisions, manage dependencies, resolve ambiguity, and move complex product decisions forward
• Drive adoption, governance, measurable impact, data quality, trust, access governance, supportability, and communication of business outcomes
• Report to the Assistant Director of Data & Analytics Products
• Work alongside product managers, developers, analysts, and engineering squads

Marketing Project Manager II – Employer and Producer Marketing

HEDIS Medical Record Analyst – Temporary

Behavioral Health Utilization Management Clinician

Contract Digital Medication Support Network Pharmacist

Contract Digital Medication Support Network Pharmacist

Utilization Management – Inpatient Clinical Specialist

Customer Service Ambassador

Appeals Clinician I

Manager, Risk Management – Business Team

Medical Records Analyst I

Benefit Development Specialist II/III

Assistant Director – Affordability

Utilization Management Nurse

Assistant Director – Payment Integrity Policy, Implementation

Product Manager/Senior Product Manager, Actuarial Analytics, MedInsight Data Products