GuideWell Source

General

• Process provider prior authorization requests to support quality clinical outcomes for health plan members
• Coordinate, generate and track correspondence, faxes and authorizations for pre-service, concurrent and post-service reviews
• Interact with facilities, vendors, providers and staff to obtain information and records for prompt review and response
• Provide telephone customer service to members and providers, answer benefit questions, research and resolve issues, and explain products and services
• Determine contract and benefit eligibility
• Initiate and manage clinical referrals
• Verify insurance coverage and obtain authorizations when needed
• Process prior authorization requests received by phone, fax or correspondence
• Forward authorization requests to clinicians for medical review
• Enter referrals and document communications, actions and other data in departmental systems
• Provide authorization for inpatient admission, outpatient certification and prior authorization requests
• Perform assigned UM Coordinator activities and support unit goals during staffing or technology concerns
• Meet or exceed proficiency, productivity and accuracy standards
• Act as liaison between hospitals, physicians, health plans, vendors, patients and referral sources
• Assist with daily management of UM Coordinators as needed
• Provide onboarding training and precept new staff
• Provide guidance and expertise to less experienced UM Coordinators

Utilization Management Coordinator II

Cloud Engineer

• Design and operate federation and the entitlement model across accounts
• Automate access lifecycle processes for joiners, movers, and leavers
• Build workload identity patterns and eliminate long-lived keys and standing access
• Build access recertification for cloud entitlements and produce audit evidence
• Onboard applications to SSO
• Review access designs with application teams
• Integrate cloud entitlements with the enterprise identity governance platform
• Design workload and machine identity patterns, including service roles and OIDC for pipelines

IAM Engineer – Cloud Platform

Security Engineer

• Build and operate security controls embedded in GuideWell's cloud platforms across commercial, GovCloud, and secondary cloud platforms
• Implement and maintain preventive controls including SCPs, IAM policies, permission boundaries, encryption, and secrets management
• Configure, tune, and operate detective controls and drive findings to remediation
• Build PHI data protection controls, including lower-environment test data handling
• Automate evidence collection and support audit and assessment cycles
• Review application and vendor designs and respond to cloud security escalations
• Build the cloud logging pipeline feeding the security operations center
• Deliver controls through Terraform and CI/CD
• Produce control evidence for HITRUST, HIPAA, SOC 2, FedRAMP, and internal audit
• Manage encryption and KMS key architecture across accounts

Cloud Security Engineer

Claims Specialist

• Process and adjudicate medical, dental, vision, and mental health claims
• Research claims where applicable across varying levels of complexity
• Review insurance to verify medical necessity and coverage under policy guidelines using clinical edit logic
• Meet and/or exceed qualitative and quantitative production standards
• Facilitate claims investigations and negotiate settlements
• Interpret medical records and respond to Department of Insurance complaints
• Authorize payments to claimants and providers
• Review and recover claims overpayments and correct financial histories
• Track complaints and resolutions using designated systems
• Resolve claims appeals
• Research benefits and verify correct plan loading

Claims Examiner I – Part Time

Customer Support

• Successfully complete the training program
• Answer inbound calls from providers and members
• Resolve questions about benefits, claims, and eligibility
• Document notes for each call
• Meet Customer Service metrics for after-call work time, hold time, staff time, talk time, and quality
• Handle callbacks and escalations as necessary

Customer Service Representative, Part Time

• Perform medical reviews using established criteria to ensure members receive care at the most appropriate level
• Build relationships with facility case managers to facilitate appropriate care and discharge planning
• Identify appropriate care programs to support smooth transitions from facility to home and decrease readmissions
• Serve as a point of contact for providers navigating members through the continuum
• Educate providers regarding benefits
• Identify candidates for Care Programs
• Provide information about the network and network access
• Evaluate members in hospitals, skilled nursing facilities, LTACs, and acute inpatient rehabilitation for benefit determination, medical necessity, and appropriate level of care using member benefits and InterQual or other medical necessity criteria
• Participate in weekly case review
• Determine member discharge status and coordinate additional needs and services requiring ongoing Care Coordination
• Collaborate with Medical Directors, managers, coworkers, Case Management, Care Partners, and other departments

Part-Time Concurrent Review RN – Every Saturday and Sunday

Analyst

• Review and research provider appeals to reach a final determination
• Review provider appeals and medical documentation
• Review CMS-1500 forms or equivalent electronic counterparts for proper coding
• Access Legacy or Diamond to review how claims were originally processed by BCBSF
• Assist appeal coordinators with clinical research and appeal processing in accordance with ERISA, HIPAA, and corporate/departmental standards
• Interpret BCBSF Medical Coverage Guidelines for staff
• Collaborate with the Managing Medical Director to facilitate changes to BCBSF Medical Coverage Guidelines
• Research, prepare, and present clinical appeal cases to the Provider Appeal Panel
• Work with business partners to gather data for final determinations
• Follow regulatory requirements and corporate values, policies, and procedures
• Ensure final determinations are reached and communicated to providers within strict timelines
• Document findings and render final determinations in BCBSF systems and SQL databases
• Create statements in final provider documents supporting final determinations

Healthcare Appeals Analyst, RN

Accountant

• Prepare and review financial statements, including balance sheets, income statements, and cash flow statements
• Analyze financial data and provide strategic recommendations to management
• Ensure compliance with accounting standards and regulations
• Manage and reconcile high-volume and complex general ledger accounts
• Prepare and process complicated journal entries
• Collaborate with external auditors and provide support during audits
• Supervise and mentor junior accounting staff
• Provide technical guidance and support to other departments on accounting-related matters
• Stay up to date with changes in accounting standards and regulations and implement changes as necessary
• Manage and oversee accounting and financial functions
• Maintain accurate financial records

Senior Accountant

Care Coordinator

• Work with administration, Care Managers, patients, and family members to reach healthcare goals and maintain communication
• Support non-clinical duties and provide additional support to clinicians, case managers, and members related to patient care
• Serve as a resource contact and education source to patients, families, providers, and staff
• Provide telephonic follow-up with members, including post-hospital discharge and chronic condition management
• Complete assigned Care Coordination tasks
• Generate tasks for the assigned RN Case Manager
• Direct patients and families to appropriate resources, including community resources
• Assist, under RN Case Manager direction and supervision, with member goals, education, resource access, and follow-up care arrangements
• Maintain quality service according to organizational standards
• Assist with data entry, faxes, filing, and other clerical duties
• Handle inbound and outbound calls and obtain information as requested by licensed staff

• Process and adjudicate medical, dental, vision, and mental health claims
• Research claims where applicable across varying levels of complexity
• Review and process insurance to verify medical necessity and coverage under policy guidelines using clinical edit logic
• Meet or exceed qualitative and quantitative production standards
• Facilitate claims investigations
• Negotiate settlements and interpret medical records
• Respond to Department of Insurance complaints
• Authorize payments to claimants and providers
• Review and recover claim overpayments
• Correct financial histories for patients and service providers
• Track complaints and resolutions using designated systems
• Resolve claims appeals
• Research benefits
• Verify correct plan loading

Claims Examiner I

• Process claims daily for accounts
• Process medical, dental, vision, and mental health claims
• Perform claims processing and adjudication
• Conduct claims research where applicable
• Review and process insurance to verify medical necessity and coverage under policy guidelines using clinical edit logic
• Meet and/or exceed qualitative and quantitative production standards
• Facilitate claims investigations
• Negotiate settlements
• Interpret medical records
• Respond to Department of Insurance complaints
• Authorize payments to claimants and providers
• Review and recover claim overpayments
• Correct financial histories of patients and service providers
• Track complaints and resolutions using relevant systems
• Resolve claims appeals
• Research benefits
• Verify correct plan loading

• Process medical, dental, vision, and mental health claims
• Perform claims processing and adjudication across varying claim complexity
• Research claims where applicable
• Review and process insurance to verify medical necessity and coverage under policy guidelines
• Meet or exceed qualitative and quantitative production standards
• Facilitate claims investigations
• Negotiate settlements
• Interpret medical records
• Respond to Department of Insurance complaints
• Authorize payments to claimants and providers
• Review and recover claim overpayments
• Correct patient and service-provider financial histories
• Track complaints and resolutions in relevant systems
• Resolve claims appeals
• Research benefits
• Verify correct plan loading

Advocate

• Review and adjudicate high risk claims
• Process credit listing functions, aged listings, and held claims
• Process adjustments by working with ambulance services, inpatient facility services, and others
• Determine whether to return, deny, or pay claims following contract benefit and organizational processing guidelines
• Conduct additional research to develop claims, including contacting providers or members
• Provide customer service and education to plan members and providers regarding insurance claims and policies
• Answer complex questions, resolve issues, and explain company products, services, and processes
• Research inquiries and interpret policy provisions to determine effective responses
• Use computerized systems for tracking, information gathering, and troubleshooting
• Identify and implement process improvement opportunities
• Perform other assigned duties

Service Advocate III, FEP Claims Processing

User Researcher

• Unearth customer insights to guide the user experience
• Provide actionable, meaningful, data-driven insights representing multiple users
• Evaluate current and upcoming user research needs across development, design, and marketing teams
• Design and conduct exploratory and concept-validation research
• Deliver formative and summative research in cadence with the design process
• Partner with designers, product managers, developers, and other stakeholders on cross-functional product teams
• Create research strategies and coordinate participant recruitment
• Facilitate usability studies and work directly with research participants
• Generate insights influencing product strategy, feature design, and prioritization
• Present findings and insights to stakeholders
• Plan, prioritize, and manage research projects
• Serve as liaison with stakeholders

Senior UX Researcher

• Process medical, dental, vision, and mental health claims
• Adjudicate claims and conduct claims research
• Review insurance to verify medical necessity and coverage under policy guidelines
• Meet or exceed qualitative and quantitative production standards
• Facilitate claims investigations and negotiate settlements
• Interpret medical records
• Respond to Department of Insurance complaints
• Authorize payments to claimants and providers
• Review and recover claim overpayments
• Correct patient and provider financial histories
• Track complaints and resolutions using designated systems
• Resolve claims appeals
• Research benefits
• Verify correct plan loading