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  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #929
    Wednesday, November 6, 2019
    JOB SUMMARY:Provide leadership and guidance to organization related to the administration of medical services; ensure quality of medical care, efficiency, quality, and affordability of healthcare services. Enhance and maintain relationships with the provider community. Perform utilization review functions for plan; ensure organization is compliant with federal, state, and local laws, along with accreditation standards. Provide leadership, technical expertise, and motivation to reshape the health ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #923
    Wednesday, November 6, 2019
    JOB SUMMARY:Optimize member benefits to promote effective use of resources.  Conduct pre and post payment review of inpatient admissions, outpatient services, and other procedures to assess the medical necessity and appropriateness of services on-site or in-house.  Discuss cases with attending physician and other health care professionals. Prepare and refer concerns to plan Medical Directors.  ESSENTIAL JOB FUNCTIONS:Conduct pre and post payment review of inpatient admissions, outpatient service ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #924
    Wednesday, November 6, 2019
    JOB SUMMARY:Act as department lead for payment controls, rate changes, and coordination of system configuration activities.  Ensure successful implementation of approved negotiated contracts, administration of provider fee schedules, data integrity audits and reporting for internal stakeholders. Ensure reimbursement methodology, fee schedule and provider contracts are prepared for system configuration according to approved standards, accurately and timely. Lead the coordination of new reimbursem ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #925
    Wednesday, November 6, 2019
    JOB SUMMARY: Design and develop internal controls programs to ensure compliance with Sarbanes-Oxley (SOX) requirements and Model Audit Rule (MAR).  Assess the effectiveness of internal controls in accordance with internal auditing and government-mandated standards.  Identify control deficiencies and make recommendations to improve the efficiency of operations and the control environment.  ESSENTIAL JOB FUNCTIONS: Lead the design and development of an effective internal controls and corporate ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #919
    Wednesday, October 23, 2019
    JOB SUMMARY: Prepare group-specific subscriber agreements and benefit booklets for distribution.  Ensure documentation adheres to all state laws and regulations, accurately reflects benefits purchased by employer groups, and is prepared within established time frames.  ESSENTIAL JOB FUNCTIONS:Develop and modify group-specific benefit booklets that clearly represent the terms and conditions of the company‚Äôs self-funded, and custom large group fully insured health plan offerings.  Collaborate with ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #912
    Tuesday, October 22, 2019
    JOB SUMMARY:  Lead organization wide efforts to ensure security of all systems. Develop management reporting and metrics for trending of vulnerability and configuration management and overall organizational compliance to regulations.  Balance policy requirements with business needs. Identify, recommend, and lead efforts for process improvement opportunities within information security. React to and initiate corrective action regarding security violations, including conducting leading investigat ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #898
    Monday, October 7, 2019
    JOB SUMMARY: Serve as primary business lead in execution of new and existing initiatives on the Salesforce platform. Based on Salesforce experience, drive advancement of transformation within existing business processes, as well as assist users to develop revised and new leaner processes using Salesforce.  Lead all phases of the agile lifecycle to ensure proposed solutions meet business needs and align with divisional strategies. Act as the conduit between platform users and the agile deve ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #913
    Monday, October 7, 2019
    JOB SUMMARY: Assist members in navigating the health care system, ensuring access to evidenced based care. Educate, empower, and coordinate services for members to improve their health and well being. Facilitate communication between patient, provider, and health plan to ensure members receive the full benefit of integrated care. ESSENTIAL JOB FUNCTIONS:Manage members through the healthcare delivery system; assess needs in order to identify appropriate interventions. Conduct telephonic or face t ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #910
    Friday, October 4, 2019
    JOB SUMMARY:   Ensures that the organization operates in compliance with applicable federal, state, and corporate requirements as they relate to information technology.  Responsible for insuring the confidentiality, integrity and availability of the company's electronic information assets, overseeing the proper implementation of administrative and technical controls, and protecting them against unauthorized modification, disclosure and destruction.   ESSENTIAL JOB FUNCTIONS ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #909
    Thursday, October 3, 2019
    JOB SUMMARY: Responsible for leading the day-to-day management of multiple internal strategy consulting engagements simultaneously. Focuses on high-complexity, high-impact strategic and operational business priorities of our executive team, including enterprise strategy and projects for senior divisional stakeholders. Implement the evaluation and planning of strategic initiatives and capital investments, including corporate development activities. Oversee aspects of strategy implementation, ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #907
    Thursday, October 3, 2019
    JOB SUMMARY: Actively participate in all phases of system design, development and integration to ensure that design solutions meet business needs and align with enterprise strategy and standards. Support technical requirement definition, functional specifications, design documentation, vendor selection, and vendor integration as core team member of project teams.     ESSENTIAL JOB FUNCTIONS : Participate in shaping overall technology strategy including software ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #902
    Wednesday, October 2, 2019
    JOB SUMMARY:Perform on-site medical record reviews of Medicare Advantage members to ensure proper medical diagnoses are being submitted to Centers for Medicare & Medicaid Services (CMS) for accurate risk adjustment payments.  Perform data validation of collected medical codes from both outpatient and inpatient settings.  Assist with the review and retrieval of medical records for internal and external audits. ESSENTIAL JOB FUNCTIONS:Perform risk adjustment data validation of Medicare Advantage m ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #889
    Monday, September 9, 2019
    JOB SUMMARY: Assist members in navigating the health care system, ensuring access to evidenced based care. Educate, empower, and coordinate services for members to improve their health and well being. Facilitate communication between patient, provider, and health plan to ensure members receive the full benefit of integrated care. ESSENTIAL JOB FUNCTIONS: Manage members through the healthcare delivery system; assess needs in order to identify appropriate interventions.  Conduct telephonic an ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #869
    Monday, August 26, 2019
    JOB SUMMARY: The Consumer Insights and Strategy Analyst will be an empirical and inquisitive thinker with a natural passion to uncover the underlying drivers of business phenomenon. The ideal candidate will possess a high degree of technical skill, with significant experience mining and manipulating large databases with tools such as SAS, Access, and/or SQL, as well as a strong working command of reporting tools such as Excel and/or Tableau.  In addition to technical acumen, the Consumer Insi ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #875
    Wednesday, August 14, 2019
    JOB SUMMARY: Support the Sales and Marketing team and contribute to the day-to-day operations and advancement of initiatives associated with Salesforce Sales Cloud. Assist with the Salesforce initiative rollout and customization, driving continuous improvement into the platform, and establishing best practices to help the business grow. Act as a first-in-line resource to the Sales and Marketing organization in helping utilize the Salesforce platform to drive business results. Deliver deep insi ... More