77 jobs found in Baltimore

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: Responsible for answering member, provider & broker inquiries pertaining to product information, benefits, claims resolution, eligibility and billing questions in a call center environment. Proactively provides information and education to members, providers & brokers, as appropriate, about a variety of health, financial, and self-service programs. Provides basic technical assistance and troubleshooting guidance for digital and electronic applications. ESSENTIAL FUNCTIONS: Provides first- level problem resolution to member, provider and broker inquiries via telephone by gathering and researching information; examine claim submissions verifying claim and system accuracy as well as liability, validate customer understanding of information and resolves issues based on applicable policies and procedures. Uses knowledge of products or services by collecting and the contractual provisions that...

American Red Cross Please use Google Chrome or Mozilla Firefox when accessing Candidate Home. By joining the American Red Cross you will touch millions of lives every year and experience the greatness of the human spirit at its best. Are you ready to be part of the world's largest humanitarian network? Join us-Where your Career is a Force for Good! Job Description: WHY CHOOSE US? Joining The American Red Cross is like nothing else - it's as much something you feel as something you do. You become a vital part of the world's largest humanitarian network. Joining a team of welcoming individuals who are exceptional, yet unassuming. Diverse, yet uncompromising in unity. You grow your career within a movement that matters, where success is measured in people helped, communities made whole, and individuals equipped to never stop changing lives and situations for the better. When you choose to be a force for good, you'll have mentors who empower your growth along a...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: Responsible for answering member, provider & broker inquiries pertaining to product information, benefits, claims resolution, eligibility and billing questions in a call center environment. Proactively provides information and education to members, providers & brokers, as appropriate, about a variety of health, financial, and self-service programs. Provides basic technical assistance and troubleshooting guidance for digital and electronic applications. ESSENTIAL FUNCTIONS: Provides first- level problem resolution to member, provider & broker inquiries via telephone by gathering and researching information; examine claim submissions verifying claim and system accuracy as well as liability, validate customer understanding of information and resolves issues based on applicable policies and procedures. Uses knowledge of products and the contractual provisions that govern administration to...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: Responsible for answering member, provider & broker inquiries pertaining to product information, benefits, claims resolution, eligibility and billing questions in a call center environment. Proactively provides information and education to members, providers & brokers, as appropriate, about a variety of health, financial, and self-service programs. Provides basic technical assistance and troubleshooting guidance for digital and electronic applications. ESSENTIAL FUNCTIONS: Provides first- level problem resolution to member, provider and broker inquiries via telephone by gathering and researching information; examine claim submissions verifying claim and system accuracy as well as liability, validate customer understanding of information and resolves issues based on applicable policies and procedures. Uses knowledge of products or services by collecting and the contractual provisions that...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The intern is an integral member of the Product team, part of the larger Enterprise Product and Specialty division at CareFirst BlueCross BlueShield. This team is responsible for the product lifecycle of CareFirsts Commercial Medical and Ancillary Products from strategic conception to launch to maintenance. Ideally this opportunity would run as a year-round internship program. The ideal candidate is someone who can work throughout the year up to 15-20 hours in the Fall/Spring AND full time (35 to 40) in the summer. This is a hybrid internship, and the student will be expected to come into the office once per week. ESSENTIAL FUNCTIONS: Seek to learn and understand insurance products in-depth. Analyze and gather competitive intelligence information for differing lines of business (medical, dental, pharmacy, life, disability, wellness, etc.). Analyze market and segment competitors. Conduct ad hoc...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: Responsible for collecting, preparing, analyzing, and interpreting financial data.. Interfaces regularly with divisional managers to ensure expenses are properly recorded per GAAP Accounting standards. ESSENTIAL FUNCTIONS: Analyzes and prepares journal entries and monthly account reconciliations, responding to internal and external auditors, management, and finance department inquiries. Prepares various accounting and financial reports, analyzes and verifies data and financial reports to produce the financial results for assigned business units and challenge accounting processes. Analyzes trends, calculates variances to the budget and verifies data. Interfaces with other areas to develop reporting specifications, methods and procedures, and prioritizes requests. Performs moderately to complex analysis, gathers, compiles and interprets financial data to ensure compliance with applicable...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Senior Data Architect will support the design and implementation of enterprise data architecture across strategic initiatives. As a key leader in the organization, you will leverage your expertise in architecture, governance, integration, and analytics to enable data-driven decisions and regulatory compliance in a highly complex healthcare environment. This role requires effective leadership skills, technical expertise, and strategic thinking as it involves collaboration with cross-functional teams to ensure the integrity, scalability, and performance of our data platforms and analytics ecosystems. You will be responsible for the development of data models, data integration strategies, and data governance policies to implement industry best practices and advance the organizations modernization journey consistent with the enterprise data strategy. ESSENTIAL FUNCTIONS: Architecture and Design: Lead...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: Under the supervision of the Director, Cybersecurity Strategy, the Cybersecurity Project Manager is accountable for leading and coordinating multiple cybersecurity initiatives to ensure alignment with organizational objectives. The role focuses on driving continuous improvements in program management processes and engagement planning, fostering effective collaboration with stakeholders, and maintaining clear communication throughout project lifecycles. It includes proactively identifying and mitigating risks supporting the Cybersecurity Officers to safeguard deliverables while providing guidance and support to team members to promote accountability and professional growth. ESSENTIAL FUNCTIONS: Partner with the Cybersecurity Officers as an advisor to determine critical gaps, cybersecurity capabilities, as well as provide strategic support to the Cybersecurity organization. Partner with the...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The intern is an integral member of the Product Management Team, part of the larger Enterprise Strategy and Development Division at CareFirst BlueCross BlueShield. This team is responsible for the product lifecycle of CareFirsts Commercial, Government, Medical and Ancillary Products from strategic conception to launch to maintenance. Ideally this opportunity would run as a year-round internship program. The ideal candidate is someone who can work throughout the year up to 15-20 hours in the Fall/Spring AND full time (35 to 40) in the summer. This is a hybrid internship and the student will be expected to come into the office once per week. ESSENTIAL FUNCTIONS: Seek to learn and understand insurance products in-depth. Analyze and gather competitive intelligence information for differing lines of business (medical, dental, pharmacy, life, disability, wellness, etc.). Analyze market and...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: Performs complex analysis, design, development, automated unit and integration testing, and debugging of computer software ranging from operating system architecture integration and software design to selection of computer systems, language, and/or equipment. Designs, codes, tests, develops, and documents application programs for computer systems. Works with end-users and project stakeholders to define system scope and objectives. Manages modifications to and maintenance of operational programs and procedures. Leads stakeholder and product owner meetings to define software requirements and creates highly complex systems. Acts as a mentor to junior engineers. ESSENTIAL FUNCTIONS: Lead a team of software engineers in the design, development, and implementation of multiple applications. Performs and leads the detail technical design, coding, code review and testing of new applications and enhancements of...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Clinical Appeals Nurse completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions. The Clinical Appeals Nurse utilizes clinical skills and knowledge of all applicable State and Federal rules and regulations that govern the appeal process for Commercial and Federal Employee Programs lines of business in order to formulate a professional response to the appeal request. ESSENTIAL FUNCTIONS: Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stake holders and any other initiators. Responds to such requests with original letters, complex and technical in nature, upholding corporate policies and decisions while meeting all State and Federal regulations and mandates. Organizes the appeal case for...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Assistant General Counsel II provides a complete range of highly specialized legal services in support of the General Counsel, Deputy General Counsel, Director, Managing Assistant General Counsel, and executive management in the Division(s) to which the Assistant General Counsel is assigned, and may represent CareFirst, Inc., its subsidiaries, and/or affiliates ("the Corporation") in litigation brought by and or against it. The Senior position is expected to work independently and provide high-level executive support. This position will support the Company's care delivery operations, including comprehensive representation of various provider entities. ESSENTIAL FUNCTIONS: Legal Advice Provides written and oral advice directly to executive management and/or their designees in complex and rapidly evolving areas of the law. Analyzes and provides legal guidance on a wide range of regulatory,...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: Configures, tests and documents configuration solutions for provider reimbursement configuration set-up and maintenance, benefit package configuration setup and maintenance, membership configuration set-up and maintenance, setup of code sets used for configuration in benefits & pricing for claims processing, claims editing configuration set-up and maintenance. Analyzes business requirements and objectives towards determining the optimal configuration of the requirements. Creates complex design documents through the assessment of requirements. Assesses alternatives to different designs and chooses best solution to fit business needs. Performs complex data modeling and database design with minimal oversight. Ability to multitask while prioritizing projects. ESSENTIAL FUNCTIONS: Independently performs hands-on configurations, workflow and process mapping in Guiding Care for core care management and...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: Serves as a senior authority over Product Owners and product teams, ensuring strategic alignment and clarity. Leverages extensive expertise to lead and manage complex project requirements, introducing innovative tools and best practices. Oversee the development of products to meet the needs of both internal and external clients, establishing and communicating the business value of their development and implementation. Offers strategic insights and guidance on opportunities and risks, supporting clients with informed decision-making. ESSENTIAL FUNCTIONS: Leads the development of two or more product portfolios and provides workable solutions to satisfy customer and market expectations in close collaboration with stakeholders, Product managers, product Owners, and scrum teams. Collaborates with senior leaders to identify and plan product releases by reviewing milestones with stakeholders; manages the...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Disaster Recovery Principal is responsible for the overall management, strategy, and execution of CareFirsts Disaster Recovery (DR) program. This individual contributor role works closely with a managed services provider and internal stakeholders to ensure the resilience and recoverability of CareFirsts critical and non-critical business applications and infrastructure. The position oversees the development, maintenance, and execution of DR policies, standards, procedures, and exercises, ensuring compliance with regulatory requirements and alignment with organizational objectives. The role is expected to drive innovation by leveraging AI, automation, and cloud-native technologies to enhance disaster recovery capabilities and future-proof the organizations resilience strategies. ESSENTIAL FUNCTIONS: Program Management & Innovation Establish and maintain core DR program policies, standards,...

CareFirst BlueCross BlueShield Resp & Qualifications We're hiring for a Data Scientist- ID/STRAT and Program Evaluation on the Health Economics and Reporting team at CareFirst! PURPOSE: Identifies and solves business problems by using various numerical techniques, algorithms, and models in statistical modeling, machine learning, operations research, and data mining. Uses advanced analytical capabilities to support data science initiatives. Communicates across product teams and with customers and educates on artificial intelligence, machine learning, and statistical models. Acting as a liaison and interface between analytics, business units and other departments. We are not looking for generalists who may have an IT background and various credentials like Scrum, Agile, etc. 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: We're hiring for a Manager, Data Analytics - Value-Based Care Reporting on the Health Economics and Reporting team at CareFirst! Purpose of the Manager, Data Analytics is to execute business objectives with data and ensure alignment with the vision of the company. Individual will organize the technology, processes and financial resources necessary to address the current and future analytics needs of the business. Provides thought leadership and acts as a subject matter expert in the designing and recommending of appropriate analytical approaches and methodologies. Provides management responsibility into data-driven insights that inform the business's strategic direction. We are looking for an experienced professional to live and work remotely from within the greater Baltimore/Washington metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: Provides strategic and tactical planning, as well as, knowledge services relating to the implementation of key mandate initiatives, covering a broad range of legislative and regulatory matters including: Federal, BCBSA, Government Programs, State. Provides internal and external liaison functions, workflow, customer service, communications, training, strategic delivery, efficiency, cost reduction and skill development initiatives. We are looking for an experienced professional to work remotely. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities. ESSENTIAL FUNCTIONS: Analyzes legislation and regulations as it relates to CareFirst and creates high level compliance requirements. Primary/dedicated Regulatory point of contact for Project Managers who implementation projects. Takes a lead role in various...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Onsite Clinical Navigator (RN) embedded at a partnering hospital will conduct concurrent review of inpatient level of care, managing the timely and smooth transition from inpatient care to home or other levels of care. Utilizing experience and skills in both care management and utilization management, the Onsite Clinical Navigator will leverage proficiency in established MCG, in addition to administrative/regulatory considerations, to determine medical necessity, appropriate level(s) of care and case management to engage members/enrollees, their families and other support systems in discharge planning. The role will function as a liaison working onsite at the assigned hospital up to 5 days per week and occasional weekend work may also be required, both at management's sole discretion. Such work will be conducted with the hospital care team including case managers, social workers and discharge planners...

CareFirst BlueCross BlueShield Resp & Qualifications We're hiring for a Director, Data Analytics of Health Economics and Reporting at CareFirst! PURPOSE: Purpose of the Director, Health Economics and Reporting is to oversee all activities dealing with data and ensure alignment with the business's vision and objectives. Individual will organize the technology, processes and financial resources necessary to address the current and future analytics needs of the business. Provides thought leadership and acts as a subject matter expert in the designing and recommending of appropriate analytical approaches and methodologies. Provides management responsibility into data-driven insights that inform the business's strategic direction. The primary responsibility will be to manage a team of 20+ individuals supporting the analytics, reporting and data governance activity for domains like Cost of Care, Value-Based Care, Population Health Management and Program Evaluation. We...