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  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #967
    Wednesday, January 22, 2020
    JOB SUMMARY: Generate Medicare sales through an inside sales capacity. Speak with individuals over the phone who are seeking more information about purchasing Medicare insurance and provide options to help callers select the plan that best fits their needs. ESSENTIAL JOB FUNCTIONS: Assist prospective customers (inbound and outbound calls) regarding their request for more information about Medicare Insurance. Educate clients and sell Medicare Advantage, Medicare Supplement, and Dental ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #970
    Monday, January 13, 2020
    JOB SUMMARY:Conduct complex, in-depth analysis of claim payments and its methodology, identifying trends and patterns, to ascertain cost avoidance/overpayment recovery opportunities. Apply root cause analysis to design and develop solutions to payment integrity opportunities/issues, and coordinate implementation efforts with internal stakeholders as well as vendor(s) and providers as applicable. Ensure medical claims, records and other documentation essential to claims submission and reimburseme ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #972
    Monday, January 13, 2020
    JOB SUMMARY:Act as an expert on clinical pharmacy issues.  Provide support to pharmacy program management and assist in the development and maintenance of cost-effective pharmacy programs.  Respond to internal questions concerning plan coverage and policies for specific pharmaceuticals, research appropriateness of drug therapies, and provide feedback on state regulatory and legislative issue.   ESSENTIAL JOB FUNCTIONS:Act as an expert on clinical pharmacy issues within the organization and to ex ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #965
    Tuesday, January 7, 2020
    JOB SUMMARY:Serve as an advocate for current and prospective members at retail locations.  Clarify and resolve account related questions for all lines of business. Provide an excellent customer experience by ensuring that all transactions and inquiries are addressed accurately and in a timely fashion.   Sell various types of health insurance products on behalf of Blue Cross & Blue Shield of Rhode Island. Adhere to all Centers for Medicare & Medicaid Services (CMS) guidelines and company driven c ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #964
    Tuesday, January 7, 2020
    JOB SUMMARY: BCBSRI is offering a unique opportunity to highly motivated students and recent graduates who thrive in a team oriented, fast paced and enjoyable work environment. The student intern will learn about Medicare Advantage, the health insurance industry and regulatory compliance.  As a student intern with the Medicare & Regulatory Compliance Team, the intern will be working on real business projects that make an impact on BCBSRI. The student intern will learn about departmental and ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #961
    Monday, January 6, 2020
    JOB SUMMARY:Provide specialized support to clinical staff by responding to member phone calls; facilitate problem resolution and triage calls to appropriate resource.  Provide administrative and project support to the department and/or management.ESSENTIAL JOB FUNCTIONS:Respond to inquiries from internal and external customers; facilitate problem resolution through research.  Refer call to appropriate resources in a timely manner.  Interact with clinical staff to obtain health care information n ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #962
    Monday, January 6, 2020
    JOB SUMMARY:Develop, implement and monitor compliance plans based on state and federal regulations and any applicable accreditation standards.  Evaluate regulations, educate affected staff, and conduct periodic audits of operational areas and delegated organizations to ensure effective ongoing regulatory compliance. ESSENTIAL JOB FUNCTIONS:Develop, implement and monitor regulatory compliance plans and strategies including evaluation of state and federal regulations, applicable accreditation stan ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #954
    Monday, December 23, 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 services ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #923
    Wednesday, December 11, 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 #953
    Wednesday, December 11, 2019
    JOB SUMMARY: Create and maintain a scalable, resilient, highly predictive, and cost-effective infrastructure both on premise and in our journey to the cloud. Analyze the effectiveness of existing processes and recommend effective solutions to improve operations.  Partner with Managed Service Providers (MSP) engineering solutions and ensuring the MSP execute focused on long term business value. Manage technology business continuity ensuring infrastructure and applications meet resilienc ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #947
    Tuesday, December 10, 2019
    JOB SUMMARY:Extract and analyze health care data for specific studies and corporate initiatives, assisting with data intensive projects.  Serve as a technical resource to department staff and management.  Work with management of operational areas to assist them in accumulating data to meet their needs.  Provide advice to management regarding effective techniques to analyze and report on data to display the most effective result. ESSENTIAL JOB FUNCTIONS:Perform routine to moderately complex analy ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #952
    Thursday, December 5, 2019
    JOB SUMMARY: Perform project-based strategic sourcing and vendor management across all commodities, including IT hardware and software, consulting and contingent labor, facilities, general administration and medical expense-related commodities.  Serve as a vendor management subject matter expert and administer the vendor management program. Drive and implement tailored vendor management strategies and techniques to create cost savings, manage demand for external vendor resources, and ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #927
    Thursday, December 5, 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 to ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #941
    Monday, December 2, 2019
    JOB SUMMARY: Respond to incoming requests and perform administrative duties such as answering incoming phone calls, prepare correspondence and other duties as needed in support of case preparation and departmental activities. Investigate and resolve provider liability administrative appeals for our commercial marketplace products. Ensure compliance with state and federal guidelines and maintain all appeals documentation according to external agency requirements. ESSENTIAL JOB FUNCTIONS: ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #869
    Monday, December 2, 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, and 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 Insights and Strat ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #926
    Tuesday, November 26, 2019
    JOB SUMMARY: Manage daily operations of pharmacy benefit programs; act as an expert on clinical pharmacy issues.  Oversee the development and maintenance of cost-effective pharmacy management programs.  Respond to internal questions concerning plan coverage and policies for specific pharmaceuticals, research appropriateness of drug therapies, and provide feedback on state regulatory and legislative issue.  Manage the development, implementation, and maintenance of departmental policies, procedu ... More
  • Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI, USA
    Req #928
    Tuesday, November 12, 2019
    JOB SUMMARY: Develop the strategy and architecture for migrating data assets to the cloud.  Design the standards and mechanisms for cloud governance. Lead participation in all phases of data warehouse design, development and integration. Support technical requirement definition, functional specifications, design documentation, vendor selection, and vendor integration as core team member of project teams. Oversee the architecture, design and development work for outsourced resources ... More
  • 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 #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 #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