13 legal jobs found in Baltimore

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 PURPOSE: The Clinical Medical Review Nurse handles day to day review of professional and institutional claims and provider appeals that require medical review to determine if the claim is eligible for benefits and to support claims processing and/or adjudication. The incumbent will handle pre claim medical review for Commercial and Federal lines of business. This position assists in determining acceptable medical risk to the organization by analyzing medical information of applicants for enrollment in specific policies. This role will also understand the merits of legal or accreditation actions. We are looking for an experienced RN 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: Receives, researches, reviews and analyzes...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: Your role involves managing the entire lifecycle of enterprise data products and services to align with company goals. You will lead the strategic direction of data products and coordinate teams of business leaders, data engineers, data architects, data analysts, and data scientists. As a Data Product Manager, you will establish and execute the data product operating model, define the vision and strategy for data products, implement product management processes, and produce roadmaps for high-quality, high-performing data products. You will also deliver data solutions that enhance the analytical experiences of CareFirsts customers and internal teams. You create value from the organization's data assets and enable internal/external analytics and insights. This includes developing strategies to achieve business outcomes, drive innovation, and ensure compliance with regulatory, legal, and ethical...

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 lines of business in order to formulate a professional response to the appeal request. We are looking for an experienced professional 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: Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stake holders and any other...

CareFirst BlueCross BlueShield Resp & Qualifications CANDIDATES MUST LIVE IN THE MD, DC, NORTHEN VA AREA IN ORDER TO TRAVEL INTO THE OFFICES AND FOR CLIENT MEETINGS AND STAFF MEETINGS. ACTIVE HEALTH AND LIFE LICENSE IS REQUIRED. PURPOSE: As a key member of our Account Management Team, the Account Manager II plays a pivotal role in driving client success and business growth. This position combines strategic consulting, relationship management, and marketing expertise to deliver exceptional value to our clients. Youll serve as a trusted advisor, promoting our suite of benefits and services, and leading initiatives that enhance client satisfaction, increase enrollment, and strengthen long-term partnerships. ESSENTIAL FUNCTIONS: Drive Growth & Engageme nt: Lead the charge in growing group enrollment by marketing directly to client associates. Plan and execute impactful communication and education strategies that resonate with diverse employee...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Vendor Management Manager is responsible for driving key business relationships with critical business partners, managing global partner issues, and working with internal teams such as Information Technology to ensure understanding of customer and business needs. This position will contribute to enhancing and optimizing the processes and workflows established between CareFirst and contracted vendors. In addition, the Vendor Management Manager will hold vendors accountable for contracted performance guarantees to ensure members receive the highest quality of service and ensure financial compliance to contracts. This role will manage a stable of vendors in the Information Technology space. ESSENTIAL FUNCTIONS: Responsible for overseeing the vendor management process including supervision and monitoring of Division vendor performance. Responsible for ensuring processes are in place to monitor vendor...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Paralegal III position is an advanced position for an experienced paralegal with subject matter expertise in a designated specialty area of the law, such as litigation (plaintiff and/or defense), with a focus on regulatory, compliance and employment law, providing advanced support to the attorneys in the organization and to other Divisions or Departments as directed by counsel. ESSENTIAL FUNCTIONS: Work in Specialized Area of Expertise: Proactively, monitor and manage compliance with statutory and regulatory requirements in the area of expertise, including investigating and researching complex legal matters, collecting and compiling information and documents and either timely responding to, or proposing draft responses to legal correspondence for counsels final review. Draft documents, including proposing responsive pleadings or other legal documents for counsel, compile, update, and manage all...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: To support the prevention, reduction of and/or recuperation of losses to CareFirst through the clinical review of medical records and claims, resulting in the savings and/or recovery of funds. Responsible for providing clinical knowledge to the SI team to support both prepayment reviews and/or post-payment investigations. ESSENTIAL FUNCTIONS: Review of medical records and claims. Investigate potential fraud and over-utilization by performing complex medical reviews of claims and medical records. The claims may be in a pre or post payment environment. Provide a detailed but concise analysis to communicate findings about the ability to pay or deny a claim or claim lines using clinical and/or coding, billing, or reimbursement knowledge. Maintain appropriate records and supporting documentation regarding findings in accordance with departmental standards. Process all assigned claims or batch case reviews...

CareFirst BlueCross BlueShield Resp & Qualifications CANDIDATES MUST LIVE IN THE MD, DC, NORTHEN 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 a critical resource within the Account Management Team providing consultative expertise on benefits, products, and capabilities. Responsible for promoting new and existing products or services through the development and delivery of tactical marketing and communication initiatives. The Account Manager is directly responsible for aggressively growing group enrollment by marketing to the client's associate base. Builds and maintains effective long-term relationships and a level of satisfaction with key senior-level decision makers and influencers assigned to a group of strategic clients. Creates demand for the organization's products and services by successfully managing the internal and external client...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Pharmacy Supply Chain Director is responsible for leading critical financial and analytic functions within the Pharmacy Management department. This role ensures the organization maximizes contractual value by overseeing reconciliation of pharmacy rebates and network discounts with the PBM and medical rebates with Synergies, delivers timely and accurate rebate and discount calculations to self-insured ASO/CFA accounts, and builds, maintains, and enhances enterprise pharmacy data and analytics capabilities ESSENTIAL FUNCTIONS: Pharmacy Supply Chain (Pharmacy & Medical Rebate Reconciliation): Lead the end-to-end reconciliation of all pharmacy rebates, network discounts, and medical rebates to ensure contractual financial guarantees are met. Interpret multiple complex contract terms, conditions, definitions, and financial guarantees, translating them into claim-level mapping and reconciliation...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: Manages end-to-end oversight of Pharmacy initiatives. Drives teams and internal projects to maintain and enhance program performance over time. Guides stakeholders through key decisions, communicates and coordinates activities internally and across departments. Facilitates process improvement and identifies and articulates stakeholder needs to drive pharmacy strategies and maximize outcomes related to ROI, customer satisfaction, and organizational metrics and performance. ESSENTIAL FUNCTIONS: Manages complex pharmacy program(s) or strategic initiatives that span organizational boundaries and have a significant legal and/or financial impact to CareFirst Business. Identifies process improvement opportunities and takes action to implement enhancements to maximize outcomes and growth. Coordinates with internal and external stakeholders to launch, maintain, and enhance complex pharmacy program(s)....

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: This role manages the appeal process for members and providers who appeal on behalf of members for Commercial lines of business. Ensures quality management of the clinical appeal process to reduce the risk of State and Federal Regulatory fines and sanctions, avoid adverse exposure, reiterate the expectation of a fair and compliant appeal process for our membership, and support NCQA accreditation and the Divisional Goals for Care Management. We are looking for an experienced clinical leader in the greater Baltimore 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. ESSENTIAL FUNCTIONS: Develops, establishes and implements a compliant appeal process with dynamic goals resulting in the full and...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Payment Integrity Analyst is responsible for conducting research and analysis and reviewing billing requirements, provider manuals, medical policies, and other sources as needed to identify new overpayment concepts, as well as validate all prospective and retrospective overpayment results; communicating findings to the Payment Integrity Workgroup and Management. The incumbent will be responsible for assessing and implementing new technology and recommend improvement to existing processes. In addition, they will be responsible for providing thorough analysis on their findings. ESSENTIAL FUNCTIONS: Identifies, develops, and implements new concepts that will target claim overpayment scenarios. Performs analysis on claims, provider data, enrollment data, medical policies, claim payment policies for payment integrity concepts for recovery opportunities. Performs analysis of business unit data and...