72 jobs found in Baltimore

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Medical Director oversees all activities of utilization review, care management and quality to determine the medical effectiveness of proposed treatments and approve care management plans. The critical responsibility will be the management of care delivery in a cost effective and quality assured system that will assist the organization to achieve its corporate mission of serving the health needs of members. ESSENTIAL FUNCTIONS: Ensure that the provision of health care service to the membership is compliant with the medical policies and standards. Participate in medical necessity reviews, including pre-service reviews, concurrent reviews of inpatient and post-acute care, and appeals. Serves as key resource for network physicians for peer-to-peer case discussion. Provides clinical support for utilization review, care management and quality to determine the medical effectiveness of proposed...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE : This position is accountable for the oversight of the Mandates Regulatory Operations and Reporting team. Key responsibilities include gathering, analyzing and disseminating key sources of information on Association, Federal, State and Local legislation as well as the identification and definition of requirements for mandates compliance. This position will collaborate with Public Policy and Government Affairs (PPGA), Legal, Business and Enterprise Project Management Office (EPMO) to ensure that all mandate requirements are reviewed and agreed upon by stakeholders and implemented. This position is also accountable for overseeing, providing analysis and recommendations on mandates for strategic decision making both internally and externally, and for ensuring support of the company's business objectives and compliance. ESSENTIAL FUNCTIONS: Accountable for the tracking, analysis and evaluation of new local,...

CareFirst BlueCross BlueShield Resp & Qualifications CANDIDATES MUST LIVE IN THE MD, DC, NORTHERN VA AREA IN ORDER TO TRAVEL INTO THE OFFICES AND FOR CLIENT MEETINGS AND STAFF MEETINGS. ACTIVE HEALTH AND LIFE LICENSE IS REQUIRED. PURPOSE: This position is responsible for renewing/growing a book business which includes more complex accounts with indemnity and managed care medical products, ancillary/specialty products, and life products. You will be working with Public Sector accounts with various funding arrangements and plan sponsors within state, municipal and school boards ranging in girth from 100 to 100,000+ contracts. This position drives revenue and manages current and prospective relationships to ensure success with products. Leads sales initiatives and strategies within their assigned territory. Achieves sales and profitability objectives by effectively managing new and existing accounts. ESSENTIAL FUNCTIONS: Ensures that each assigned account...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Data Analytics Intern role exists as a hiring strategy to bring in students enrolled in an accredited college or university who are pursuing at least a Bachelors degree in analytical and/or data visualization related fields to learn the business and technical side of healthcare from the ground up. Data and Analytics creates cutting edge analytic tools/visualizations to drive insights and faster decision making within the organization and provides critical support for key corporate initiatives. This role will require interaction with project stakeholders and business partners within the organization. This position will use analytically derived insights to develop and test solutions that enhance consumer engagement, improve health outcomes and reduce health care costs. This is a fast-paced, collaborative, and iterative environment requiring quick learning, agility and flexibility. This is a Year-Round...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: This RN position supports line of business. Under minimal supervision, the Care Manager researches and analyzes members' medical and behavioral health needs and healthcare cost drivers. The Care Manager works closely with members and the interdisciplinary care team to ensure members have an effective plan of care and positive member experience that leads to optimal health and cost-effective outcomes. We are looking for an experienced clinician to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities. ESSENTIAL FUNCTIONS: Identifies members with acute/complex medical and/or behavioral health conditions. Engages onsite and/or telephonically with members, family and providers to develop a comprehensive plan of care to address the member's needs at...

CareFirst BlueCross BlueShield Resp & Qualifications CANDIDATES MUST LIVE IN THE MD, DC, NORTHERN VA AREA IN ORDER TO TRAVEL INTO THE OFFICES AND FOR CLIENT MEETINGS AND STAFF MEETINGS. PURPOSE: This position is responsible for renewing/growing a book business which includes the most complex and jumbo accounts with indemnity and managed care medical products, ancillary/specialty products, and life products. This position drives revenue and manages current and prospective relationships to ensure success with products. Leads sales initiatives and strategies within their assigned territory. Achieves sales and profitability objectives by effectively managing new and existing accounts. ACTIVE HEALTH AND LIFE LICENSE IS REQUIRED. ESSENTIAL FUNCTIONS: Ensures that each assigned account renews annually and aggressively pursues growth within groups by developing and implementing account specific benefit and financial strategies. Manages and develops a set of...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: Supports Benefit Contract Management (BCM) by assisting or performing accountabilities/tasks that include but are not limited to: revising/updating contract forms and templates; reviewing contract forms, templates and related marketing materials; preparing electronic filings via SERFF; tracking status of filings; creating sample contracts; creating SBCs; organizing and circulating contract related documents; and contributing to BCM strategies and process improvements. ESSENTIAL FUNCTIONS: Reviews, clarifies and/or interprets customized/nonstandard benefit requests; provides information and decisions to operations, account implementation meetings, and other company initiative implementation meetings needed. Clarifies and ensures consistency of contract benefits with respective system benefit coders. Revises/updates contract forms and templates as appropriate and assigned. Assist or performs electronic...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Associate General Counsel provides a complete range of legal services in support of the Assistant General Counsel, Litigation General Counsel, and the Division(s), Department(s), and/or specialized areas of legal practice to which the position is assigned with a focus on regulatory, compliance, litigation, and employment law. ESSENTIAL FUNCTIONS: Provides advice and counsel to management and/or their designees in complex and rapidly evolving areas of the law; evaluates divisional and departmental initiatives and represents the corporations legal interests on intercompany management committees; researches, analyzes and writes legal memoranda and provides legal guidance on a wide variety of legal, regulatory, contractual, compliance, corporate governance and operational matters, including the interpretation and implementation of legislation; assists with and/or supports representation of the...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: This role is accountable for directing all aspects related to the monitoring of performance under the Medicaid contract and regulatory requirements and the overall state of compliance for Medicaid and Medicaid products. Reporting to the CEO, Plan Board of Directors, and Corporate Compliance Officer, the incumbent works closely with operational teams, Corporate Compliance, Mandates and Legal departments to resolve complex issues with inter-related legal and Medicaid compliance aspects. ESSENTIAL FUNCTIONS: Direct accountability for establishing an effective compliance program based on the seven core elements of compliance. Directs the activities related to the design, development, implementation and maintenance of compliance programs across all major functional areas and vendors for Medicaid within the division. Ensures internal departments understand and implement CMS and applicable state rules,...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: Provides administrative support for a Vice President / SVP. Performs advanced, diversified and confidential duties that may be administrative in nature or project based. Work requires broad and comprehensive experience, skills and a thorough knowledge of organization policies and practices. Prepares correspondence, reports, presentations, etc. Sets up meetings and may act as proxy for superior. Requires sufficient skills to communicate effectively with peers and senior level management staff. Performs complex tasks requiring the consideration of multiple variables to determine proper course of action. While tasks are complex, most decision-making can be made within pre-determined approaches. May lead and provide functional guidance to lower level support employees. Works under general guidance/supervision. ESSENTIAL FUNCTIONS: Provides day-to-day administrative support (such as calendar maintenance,...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Manager, Technology Operations Center (TOC) is a hands-on technical leader responsible for operating and evolving a modern, cloud-first Technology Operations Center. This role owns Major Incident Management, Event Management, and enterprise monitoring and observability, supporting a large-scale Azure-based application and infrastructure ecosystem. The role is deeply aligned to ITIL v4 processes, Site Reliability Engineering (SRE) principles, and AI-driven operations, leveraging Dynatrace as the primary observability platform and ServiceNow as the ITSM system of record. The successful candidate will drive measurable improvements in service reliability, incident response, and operational automation while ensuring technology services meet the high availability standards required in health care insurance. ESSENTIAL FUNCTIONS: Lead the technical and operational execution of the Technology Operations...

CareFirst BlueCross BlueShield Resp & Qualifications We are looking for an experienced professional in the greater Baltimore/Washington metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week. PURPOSE: This role will lead, guide, strategize and manage negotiations for provider-specific institutional, ancillary, and professional contracts. Key responsibilities include negotiating contract terms in accordance with regulatory requirements, analyzing financial data to evaluate implications across various business lines, while ensuring compliance with company policies and procedures, and coordinating with the Payment Transformation team to transition fee-for-service arrangements to value-based care. This role will also oversee complex projects related to provider...

CareFirst BlueCross BlueShield Resp & Qualifications We are looking for an experienced professional in the greater Baltimore/Washington metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week. PURPOSE: The main purpose of a data analyst is to find meaning in data as a thought leader so that the derived knowledge can be used to make informed decisions and assist the organization in making better business decisions. ESSENTIAL FUNCTIONS: Engages in data exploration using various programming languages (reading and writing code), requiring advanced knowledge of multiple database structures Collect, analyze, and interpret data to glean insights, and develop business appropriate recommendations Serve as an expert resource supporting data questions and issues from...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: Acts as an internal expert to ensure that as value-based reimbursement and medical policy models are developed and implemented. Provides advanced knowledge to support effective partnership with provider entities and guidance on the appropriate quality measure capture and proper use of CPT and ICD 10 codes in claims submissions. Utilizes extensive coding knowledge, combined with medical policy, credentialing, and contracting rules knowledge to help build the effective guides and resources for providers on the expected methodologies for billing and code submissions to maximize quality for FWA prevention. ESSENTIAL FUNCTIONS: Consults on proper coding rules in value-based contracts to ensure appropriate quality measure capture and proper use of CPT and ICD10 codes. Provides input on various consequences for different financial and incentive models. Supports to use of alternatives and solutions to...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE The Senior Analyst, FP&A Workforce Planning & Operations Analytics develops longrange operational forecasts, workforce capacity models, and analytical tools that guide staffing, budgeting, and servicelevel decisions. The role combines financial planning, data analytics, and workforce modeling to deliver clear insights that optimize staffing and labor costs. This position is ideal for a datasavvy analyst looking to deepen FP&A and operational strategy experience while applying advanced technical skills (SQL, Excel, Python, Power BI, MS Fabric/Azure) ESSENTIAL FUNCTIONS: Forecasting & Demand Modeling: Develop driver-based demand forecasts using enrollment, product changes, seasonality, regulatory shifts, digital adoption, and other operational trends/drivers. Translate business growth (membership, product launches, group movement) into actionable operational workload across all teams in...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Risk Adjustment Supervisor supports the execution of the corporate risk adjustment strategy across Medicare Advantage, Medicaid, and ACA markets. This role ensures operational compliance by supervising day-to-day activities, monitoring performance metrics, and facilitating cross-functional collaboration to drive cost-effective risk adjustment actions and optimize health plan performance to achieve equitable resource allocation based on population health risk profiles. This role is also responsible for overseeing the accurate collection, submission, and validation of risk adjustment data, ensuring compliance with regulatory standards and optimizing organizational performance under various risk adjustment programs. We are looking for an experienced professional in the greater Baltimore/Washington metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: Shape and execute reporting strategy for data collected. Help drive critical business decisions by analyzing metrics and designing reports. Communicate results to stakeholders and provide suggestions based on findings. ESSENTIAL FUNCTIONS: Collaborates with stakeholders to understand data needs to create reports that meets the needs of the business. Identifies functional requirements through process analysis, review of documents and procedures, and interviews and meetings with stakeholders. Occasionally works alongside Developers and the System Architects to use the requirements to design the system concept of operations from both business and technical perspectives. Analyzes data and develops observations and findings based on analysis. Creates and test reports utilizing feedback and revisions into reporting products. Conducts quality control, communicates findings, and obtains sign-off from...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Marketing Technology & Insights Intern will support Marketing Technology (MarTech) initiatives focused on data strategy and platform enablement, while also assisting with enterprise survey research efforts led by the Insights team. Approximately 75% of this role will focus on MarTech responsibilities, including marketing systems, data flows, and platform evaluation. The remaining 25% will support survey research initiatives that inform marketing, experience, and business decisions across audiences. This is a year-round internship opportunity. We are looking for students who can commit to our work up to 15-20 hours per week during the academic year in the Fall/Spring and 35-40 hours per week during the Summer. The start date for the internship will be May 18th or June 1st. ESSENTIAL FUNCTIONS: 75% Marketing Technology (Data Strategy & Platform Enablement) Support marketing data...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: This entry level position is responsible for the attainment, effective management, and profitability of a designated book of business. This position utilizes underwriting judgment and exercises a level of authority. Pricing concessions are permitted up to the designated level of authority without further review. This position works closely with Sales and Account Management to ensure that client needs are met ESSENTIAL FUNCTIONS: Works closely with the Account Manager and Underwriting Manager to provide alternate benefit plans, risk and/or funding arrangements. Update appropriate billing rate files, contracts, internal databases, etc. Complete the renewal process on smaller accounts, complete/update ASO and Stop Loss contracts and quote alternate funding arrangements with assistance from senior underwriter, consultant or management. Support attainment of corporate sales and profitability goals...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Digital Marketing Project Manager Provider & Member Engagement leads the planning, execution, and optimization of digital communications across email, web, SMS, and mobile-first channels. This role manages campaigns that support both member and provider audiences, ensuring timely, compliant, and engaging communications that align with organizational goals and customer experience strategies. ESSENTIAL FUNCTIONS: Manage end-to-end project delivery for mobile engagement/SMS, email, and web campaigns targeting both member and provider audiences. Develop project plans, timelines, budgets, and resource allocations for lifecycle, operational, and promotional communications. Coordinate with cross-functional teams including marketing, provider relations, business areas, clinical teams, compliance, analytics, product, and IT. Oversee campaign workflows from intake and strategy through build,...